Quiz 1

(Ref: Harrison 21st ed, p 2780; Harrison 20th ed, p 2555-56)  Patients of scleroderma develop NSIP (Non-specific interstitial pneumonitis) and the extent of changes predict ILD progression and mortality.  Option a, Cor pulmonale will occur in these patients due to PAH but findings of elevated JVP, Hepatomegaly and pedal edema are not described in the question. In textbook, Echocardiography is mentioned to be done every 6-12 months as follow up investigation and not for extent and subtype of disease.  HRCT would be required to demonstrate the exact extent of interstitial changes seen on CXR and decide the site for Lung Biopsy which will confirm presence of NSIP. NSIP has a better prognosis as compared to other forms of ILD.  Option c will show restrictive lung disease, but this finding is present in IPF, NSIP, UIP and does not help in differentiation between these subtypes.  Option d is ruled out as vascular lesion is not evaluated.

(Ref: Harrison 21st ed, p 2806; Harrison 20th ed, p 2005)  Option b and d are same and are ruled out since asthma and peripheral blood eosinophilia are not present.  Option c does not present with Hemoptysis.  The combination of involvement of Upper respiratory tract, Lower respiratory tract and Kidney involvement points to diagnosis as GPA which was formerly called Wegener's Granulomatosis.

(Ref: Harrison 21st ed, p 2813; Harrison 20th ed, p 1922) The key words are female patient with arm claudication and weak femoral pulses. This points to multi vessel inflammatory disease. This favors diagnosis of Takayasu arteritis. Retinal hemorrhage can be explained by Hypertension seen in these patients due to involvement of renal artery. Option a will not have weak femoral pulses. Option b will affect distal pulses like Dorsalis pedis or posterior tibial artery. Option d will present with renal failure, arthritis and mononeuritis multiplex.

(Ref: Harrison 21st ed, p 2811; Harrison 20th ed, p 2584) The objective of treatment in giant cell arteritis is to prevent visual loss, manage large vessel inflammation and reduce symptoms. The symptoms respond very well to glucocorticoid therapy.

(Ref: Harrison 21st ed, p 2792; Harrison 20th ed, p 2564) The combination of heel pain, low backache with morning stiffness and extra articular manifestation of iritis points to ankylosing spondylitis. Option a will have short duration back pain and will not have heel pain and iritis. Option c will have extensor plantars and palpable gibbus in spine. Option d will have radicular pain and will not have iritis

(Ref: Harrison 21st ed, p 2762; Harrison 20th ed, p 2536-39) Hydroxychloroquine on long term basis can lead to Bull's eye maculopathy with development of hazy vision, blind spots, haloes around lights and increased sensitivity to light.

(Ref: Harrison 21st ed, p 1300; Harrison 20th ed, p 962, 2568) The clinical history is suggestive of reactive arthritis and the organism responsible is shigella. Asymmetrical, predominantly lower-extremity, oligo-arthritis is the major presenting feature. Extra Mile The classic triad of Reactive arthritis features: Can't pee, Can't see, Can't walk  Noninfectious urethritis  Conjunctivitis  Arthritis **This triad is found in only 1/3rd of the patients