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Confirm diagnosis with a test for rheumatoid factor
16%
48/299
Confirm diagnosis with elevated ESR and CRP
9%
27/299
Test for latent mycobacterial infection
69%
207/299
Obtain a radiograph demonstrating osteophytes
1%
4/299
Obtain an exercise stress test
2%
6/299
Select Answer to see Preferred Response
This patient has rheumatoid arthritis (RA). Immunosuppression with TNF inhibitors can lead to reactivation of latent infection, and patients must be screened for latent tuberculosis prior to initiating therapy. Infliximab is a recombinant human protein that binds to and sequesters TNF. It is a commonly used biological therapeutic in rheumatoid arthritis, as well as several other autoimmune conditions. However, the resultant immunosuppression can result in reactivation of latent infection, including latent tuberculosis (Tb). Patients should have a negative tuberculin skin test, or else have treatment for latent Tb prior to initiating TNF inhibitor therapy. Wasserman discusses treatment for rheumatoid arthritis, the most commonly diagnosed inflammatory arthritis. Initial evaluation should include a CBC to screen for anemia related to rheumatoid arthritis. Methotrexate is generally considered first-line therapy for RA, but in patients with contraindications or refractory RA, biologic agents (including TNF inhibitors) are effective therapy. Patients should be screened for latent Tb, hepatitis B and hepatitis C before initiating biologic therapy. Jain and Singh review the adverse effects of TNF inhibitors in rheumatic disease. In addition to opportunistic infections, TNF inhibitors may lead to worsening of heart failure in the elderly. The literature regarding the affect of TNF inhibitors on cancer risk is conflicting; however, increased risk of non-melanoma skin cancer was observed across several studies. Illustration A shows a radiograph of a normal hand compared to classic hand deformities in RA. Note the extensive erosions at the articular surfaces. Illustration B schematically compares classic findings of rheumatoid vs osteoarthritis. Illustration C shows a radiograph of classic findings in osteoarthritis, including osteophytes, which are not commonly seen in rheumatoid arthritis. Incorrect Answers: Answer 1: Anti-citrullinated protein antibodies are more specific for RA than rheumatoid factor (RF). RF can be seen in a variety of autoimmune conditions. Determining RF status would not provide additional diagnostic information. Answer 2: ESR and CRP are elevated in RA, but are very non-specific. Answer 4: Osteophytes are classically seen in osteoarthritis. Answer 5: It is unnecessary to obtain a stress test for this patient.
3.7
(6)
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