After getting the lab results, you decide to start treatment with prednisone and azathioprine. However, after 6 weeks with this therapy, the patient’s renal function worsens (requiring dyalisis) and proteinuria increases to 5.9 grams in 24 hours. The edema becomes more pronounced and she has erythematous lesions in her cheeks and nasal dorsum.

Which is your best therapeutic option?

You decide to perform a renal biopsy.

Which is the most probable result, according to prevalence?

What percentage of patients with this disease and renal involvement reach end stage renal disease, regardless of therapy?

A 6-year-old boy is taken by his parents to the Emergency Room because he has had fever for the past week, along with erythematous tongue, fissured lips, adenopathies and chest pain. The ecocardiogram shows aneurysmatic dilatations in his coronaries.

Which is the most probable diagnosis?

The treatment of choice is:

Which anti-inflammatory agent is recommended for this patient?

A 37 year-old women presented with complaint of cold-triggered pallor, followed by cyanosis and erythema of the fingers during the last five years. Three years ago, she started to notice that her skin was thickening, presented pyrosis and progressive dyspnea. On physical examination, her vital signs were normal, she had salt and pepper hyperpigmentation on thorax. The abdominal examination was irrelevant. There was skin thickening proximal to the metacarpophalangeal joints and she had multiple fingertip ulcers. The pulmonary exam did not show alterations and all her laboratory test were normal.

According to the patient’s history, what would be the first step in her evaluation?

According to the clinical examination, what variety of the disease the patient presents?

Which studies are mandatory at baseline

Which antibody is associated with the pulmonary alterations?

Which is the first line therapy for Raynaud phenomenon?

A 5 year-old child was admitted to the hospital because of the presence of abrupt and purposeless movements. He had a history of recurrent superior airways infections, and suffered from scarlet fever 2 weeks ago. On physical exam his heart rate was 110 per minute, and his temperature was normal. Thorax examination revealed a mitral

The most likely diagnosis is:

The diagnosis is supported by the presence of:

The following is considered an etiologic factor of the disorder:

One of the pathophysiologic pathways involves:

The following is a useful treatment for the articular manifestations of the disease:

A 59-year -old man is evaluated for a 6-month history of gout. He was doing well on colchicine and allopurinol but developed hypersensitivity to allopurinol, which resolved with cessation of the agent. He then began to have more frequent gout fla res; two flares occurred in the past month and were treated with prednisone.

Current medications are colchicine, lisinopril , metoprolol, and simvastatin

Laboratory studies reveal a serum creatinine level of 2.3 mg/ dL, a serum urate level of 9.2mg/dL and normal liver chemistry studies; estimated glomerular filtration rate is 48 mL/min /1.73 m2.

Which of the following is the most appropriate next step in management?

A 65 year old man is evaluated for severe abdominal pain. joint pain, and a rash. He states that he had an upper respiratory infection about 10 days ago. Three days ago he noted a rash on his lower extremities. One day later, he experienced pain in his knees and ankles, along with abdominal pain that worsened over the past two days. He reports no visual symptoms. numbness, weakness, or other symptoms.

On physical examination, the patient appears uncomfortable. The chest and cardiac examinations are unremarkable. Decreased bowel sounds and diffuse abdominal tenderness without rebound are noted. The knees and ankles are tender and mildly swollen. Palpable purpuric lesions are present on the lower extremities, including the soles of the feet. The remainder of the physical examination reveals no abnormalities. Laboratory studies show a normal complete blood count, an erythrocyte sedimentation rate of 88 mmhr, serum creatinine level of 1.7 mg/dL. and a urinalysis showing 3+ protein, 20-30 erythrocytes/hpf. 20-30 leukocytes hpf. and mixed granular and celular casts. A stool test is positive for occult blood.

Which of the following is the most appropriate therapy at this time?

A 42-year-old woman is evaluated for a 4 year history of diffuse muscle and joint pain, most notably of her shoulders, low back, hips, and knees. the pain is present in the morning and throughout the clay. She wakes unrefreshecl and reports problems with her memory. She also describes diarrhea alternating with constipation with no blood or mucus in the stool. She reports no weight loss. She quit working 2 years ago clue to her symptoms, which were made worse by her work as a baker. She has been to multiple medical providers who have not established a diagnosis despite numerous tests.

On physical examination, temperature is 37.2 °C, blood pressure is 134/88 mm Hg, pulse rate is 92/ min, and respiration rate is 16/min. BMI is 36. Muscles are generally tender to light palpation but without weakness on muscle strength testing. '!he remainder of the examination is normal. Laboratory studies, including complet e blood count, chemis try panel, erythrocyte sedimentation rate, serum creatine kinase, and thyroid-stimula ting hormone, are normal.

Which of the following is the most likely diagnosis?

A 28 year old woman seeks preconception counseling. She has a 4-year history of systemic lupus erythematosus (SLE) with manifestations of photosensitive rash, arthritis. And pericarditis; she has been treated with hydroxychloroquine and low-dose prednisone with good control of her symptoms for 18 months. She has never been pregnant. She also takes vitamin D and calcium. The physical examination and vital signs are normal. Laboratory studies indicate that the patient's SLE is quiescent. A recent urinalysis is normal, and a previously checked antiphospholipid panel and lupus anticoagulant were negative.

SLE antinuclear antibody proille:

Antinuclear antibodies: Positive (titer: 1:320), speckled pattern

Anti Ro/SSA antibodies:. Positive

Anti-double-stranded DNA: Negative

Antibodies Anti- Ul-ribonucleoprotein: Negative

Antibodies Anti Smith antibodies: Negative

The increased risk of preeclampsia and preterm delivery in SLE as well as avoidance of NSA!Ds prior to conception and in the later stages of pregnancy is discussed.

Which of the following also needs to be discussed with tltis patient based on her antibody proille?

A 52-year-old woman is evaluated for an 8-week history of fatigue and shor tness of breath. She has gastroesophageal reflux disease, hypertension, a nd a 3-year history of limited cutaneous systemic sclerosis. Medications are omeprazole. nifedipi ne. lisinopri l. a nd aspiri n. On physical examination, temperature is 36.4 °C, blood pressure is 126/72 mm Hg, pulse rate is 114/min, and respiration rate is 20/min. BMI is 24. Oxygen saturation is 88% on ambient air. A prominent single S, is heard. The chest is clear on auscultation. Sclerodactyly and multiple healed digital pits are noted. There is no rash. Chest radiograph is normal

Which of the following is the most appropriate diagnostic test to perform next?

A 30-year-old man is evaluated for a 1-year history of low back pain. The pain frequently spreads to the buttocks but does not radiate to the legs. The pain is worse in the morning and is associated with stiffness but improves 2 hours later after he starts working. Symptoms are worse at the end of the day and duri ng the night. He takes ibuprofen with good relief of the pai n. He is otherwise healthy and reports no other joint pain. rash. diarrhea. or dysuria. On physical examination. vital signs are normal. Eye examination is normal. There is mild pain with normal range of motion in all directions of the lumbar spine. Tenderness over the buttocks is noted. There is no joint swelling or tenderness in the upper or lower extremities. There is no rash or nail pitting.

Laboratory studies are significant for an erythrocyte sedimentation rate of 40 mm/h, and HLA-827 testing is positive.

Plain radiographs of the lumbar spine and sacroiliac joints are normal.

Which of the following is the most likely diagnosis?

A 42-year-old man is evaluated in t he hospital for a 2-week history of progressive shortness of breath, with hemoptisis developing in the past 48 hours. During the past week he has also noted weakness of the left foot. numbness in the right hand. and the onset of a rash. He has a 7-year history of asthma. His only medication is an as-needed albuterol metered dose inhaler. On physical examination, temperature is 38.0 °C, blood pressure is 142 /87 mm Hg, pulse rate is 72 min. and respiration rate is 26/ min. Diffuse crackles are heard in the lung fields. Diminished sensation in the right hand and weakness on dorsiflexion in t he left foot are noted. There is palpable purpura on the arms and legs. The remainder of the physical examination is normal.

Laboratory studies:

Erythrocyte sedimentation rate: 98 mm/h

Leukocyte count: 16,000/microL (16 x 109 / L), 22% eosinophils

Creatinine: 0.8 mg/dL

lgE: Elevated

ANCA: Negative

Antimyeloperoxidase antibodies: Negative

Antiproteinase 3 antibodies: Negative

Urinalysis: Normal

Chest radiograph shows diffuse pulmonary infiltrates.

Which of the following is the most likely diagnosis?

A 42-year-old woman is evaluated fo r a 3-month h istory of symmetric proximal muscle weakness. She takes no medications. On physical examination, vital signs are normal. Symmetric weakness of the arm and thigh muscles is noted. There are no skin findings. Laboratory studies are significant for a serum creatine kinase level of 2000 U/ L and a normal thyroid-stimulating hormone level. Electromyogram shows increased insertional activity, spontaneous fibrillations, and polyphasic motor unit potentials in the proximal muscles. MRI of the thighs shows inflammatory changes in the quadriceps. A muscle biopsy is recommended, but the patient refuses.

Which of the following is the most appropriate treatment at this time?