Gout
A 35-year-old man is referred to Rheumatology for evaluation of hyperuricemia. His father has gout that has been well controlled with allopurinol. The patient's family physician ordered a serum uric acid test because of the family history of gouty arthritis. The patient's uric acid value was elevated at 10.1 mg/dL (reference range: 3.0-7.0 mg/dL). The patient has never had any attacks of gout and has no knowledge of kidney stones or underlying kidney disease. He has hypercholesterolemia and uses atorvastatin 10 mg daily.His physical examination is normal. No tophi are noted. His height is 59 inches, weight is 215lb, blood pressure is 124/82 mmHg, and heart rate is 76 bpm. Additional laboratory tests reveal a normal serum creatinine level.
Which of the following is recommended?
a) Allopurinol 100mg daily
b) colchicine 0.6mg BID
c) probenecid 500mg BID
d) lifestyle modification
Lifestyle modification
A 38-year-old man with psoriatic arthritis is interested in starting apremilast therapy. He has been taking oral methotrexate 20 mg weekly for 6 months without significant relief of his joint pain, although his psoriasis has improved. On initial physical examination, his blood pressure was 136/82 mm Hg, heart rate was 72 bpm, height was 68 in (172.7cm), weight was 138 lb (62.6 kg), and body mass index was 21 kg/m2. He was in no acute distress. He had psoriatic plaques on the extensor surfaces of both elbows. He had moderate tenderness and swelling of his right 2nd, 3rd, and 4th proximal interphalangeal (PIP) joints and his left knee. His right Achilles tendon was tender and swollen, and his left 3rd and 4th toe showed dactylitis. Results of his laboratory tests, including a purified protein derivative test, were within normal limits. Apremilast treatment was initiated and methotrexate was discontinued. He returns to his rheumatologist after taking aprelimast 30 mg twice daily for the past 4 months. He thinks his joint pain and psoriasis have improved significantly. He feels well and denies any symptoms of upper respiratory infections, fevers, diarrhea, or depression. He has recently traveled to India but denies any other recent travel history. On physical examination his blood pressure is 132/84 mm Hg, heart rate is 68 bpm, weight is 122 lb (55.3 kg), and body mass index is 18.5 kg/m2. He has new temporal wasting. He has no active psoriatic plaques. He also has mild tenderness and swelling of his right 2nd PIP joint. His left 3rd toe shows dactylitis. His current medications include apremilast 30 mg twice daily and folic acid 1 mg daily. Which of the following is the most appropriate next step in management?
A. Begin treatment for Mycobacterium tuberculosis
B. Discontinue treatment with apremilast
C. Perform colonoscopy
D. Send a stool specimen for fecal leukocyte analysis
B. Discontinue treatment with apremilast
A 75-year-old man presents for initial evaluation of myalgia and elevated serum creatine kinase (CK) level in association with statin therapy for hyperlipidemia. His statin was stopped approximately 3 months ago by his primary care provider when increasing proximal muscle discomfort and persistently abnormal serum CK level raised concern for possible medication toxicity. He denies associated difficulty in breathing, rash or skin discoloration, and recent illness. Recently performed colonoscopy and computed tomography (CT) scans of the chest, abdomen, and pelvis are unremarkable.
The physical examination is remarkable for 3/5 muscle strength in proximal and distal muscle groups in his upper and lower extremities bilaterally. The cardiopulmonary evaluation and assessment for lymphadenopathy are unremarkable, and a skin examination reveals no erythema, hyperpigmentation, hyperkeratosis, ulceration, or vasculitic lesions.
Results of electromyography are consistent with an irritable myopathy, and magnetic resonance imaging of his thighs revealed evidence of bilateral edema, muscle atrophy, and fatty replacement. A quadriceps muscle biopsy shows myofiber degeneration, necrosis, and regeneration, with minimal inflammatory changes.
Laboratory studies include: Aldolase 2.0 IU/mL (normal), Antinuclear antibody 1:80, Creatine kinase 10,000 IU/L, Creatinine 0.8 mg/dL, Urine myoglobin Negative
Which of the following antibodies is most likely to be positive in this patient?
A. Antiribonucloprotein (anti-RNP)
B. Anti-Jo1
C. Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR)
D. Anti-Mi-2
E. Antinuclear matrix protein 2 (anti-NXP-2)
C. Anti HmgCoA Reductase
A 23-year-old man with rheumatoid arthritis currently taking methotrexate 20 mg once weekly, folic acid 1 mg daily, and adalimumab 40 mg subcutaneously every 14 days presents for routine follow-up. He reports he is taking his medications and has 15 minutes of morning stiffness. He has read that people with rheumatoid arthritis are at increased risk of developing shingles, and he inquires about vaccination. He is up-to-date on COVID-19 and influenza vaccinations, and he completed all recommended childhood vaccinations. On examination, he has no tender or swollen joints.
Laboratory tests show: Albumin 4.1, Alk phos 72, ALT 27, AST 23, CRP 0.7, ESR 12, Creatinine 0.8, hemoglobin 15, WBC 6200, Platelets 162k
You discuss options regarding recombinant zoster vaccine. Which would you recommend for this patient?
A) RZV at age 50 followed by a second dose at 1 month
B) RZV at age 50 followed by a second dose at 6 months
C) RZV now followed by a second dose at 1 month
D) RZV now followed by a second dose at 6 months
C) RZV now followed by a second dose at 1 month
A 34-year-old woman with a history of systemic lupus erythematosus (SLE) and recent diagnosis of nephritis presents with concerns of a flare. She was diagnosed with SLE 2 years ago based on a malar rash, arthritis, low complement levels, positive antinuclear antibody (ANA) titer 1:640 homogenous pattern, and high-titer anti–double-stranded DNA antibody. Six months ago, she developed proteinuria without hematuria or pyuria and was found to have Class V lupus nephritis on renal biopsy. She was treated with mycophenolate mofetil and tapering doses of glucocorticoids with good response and had been stable on mycophenolate mofetil 3 g daily with prednisone 2.5 mg daily.
Today, she reports having worsening joint pain and swelling as well as low-grade fevers to 99.8 °F (37.7 °C) over the past 2 weeks. She has also had a poor appetite, abdominal pain, and nonbloody diarrhea, occurring twice daily. She increased her prednisone to 30 mg daily at the onset of her symptoms, which helped with joint pain and fever, but her abdominal pain, anorexia, and diarrhea have persisted. She denies recent travel or known sick contacts. She denies dining at restaurants and consumes only bottled water.
On physical examination, vitals show a temperature of 99.4 °F (37.4 °C), blood pressure of 112/78 mmHg, and heart rate of 102 bpm. Her lungs are clear to auscultation. Cardiac examination shows tachycardia with a regular rhythm and no murmur. Abdominal palpation elicits mild tenderness diffusely, but normal bowel sounds are heard. Examination of the joints reveals tenderness without synovitis at the metacarpophalangeal joints, wrists, knees, and ankles, bilaterally.
Blood tests from 3 months ago showed normal creatinine and transaminase levels and a normal white blood cell count and differential. Laboratory results from today are shown below. In addition, a urinalysis is negative for proteinuria. Blood and urine cultures show no growth to date. Stool hemoccult is negative. An abdominal radiograph is normal.
Albumin 4.0, ALT 104, AST 99, Alk Phos 75, dsDNA 7, tBili 1.0, C3 120, C4 34, Creatinine 0.9, WBC 2800, ALC 500.
Which of the following is most likely to establish this patient's diagnosis?
a) Nasal swab for COVID-19
b) PCR for CMV
c) Modified acid-fast staining for Cryptosporidium
d) Stool antigen for Clostridium difficile
b) PCR for CMV
Recent findings provide insight into the molecular processes underlying the inflammatory conditions of gout and pseudogout and further support a pivotal role of the inflammasome in several autoinflammatory diseases.
Which interleukin (IL) is activated by monosodium urate (MSU) crystals and is also known to be activated in other autoinflammatory diseases?
A. IL-1-beta
B. IL-5
C. IL-6
D. IL-17
IL-1 Beta
A 25-year-old woman with a 5-year history of inflammatory lower back pain presents for further management of her symptoms. She also notes alternating buttock pain and left heel pain. Her calculated Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score is 6.20, corresponding to high disease activity. She has no history of psoriasis, inflammatory bowel disease, conjunctivitis, or uveitis. She also denies history of peripheral arthritis and enthesitis. She has a positive family history of ankylosing spondylitis (AS) in her father but denies family history or personal history of psoriasis or inflammatory bowel disease. On examination, her vital signs are stable. No psoriatic skin or nail changes are noted. She has no synovitis. She does have tenderness in her left heel at the origin of her plantar fasciia. FABER test is positive bilaterally. Sacroiliac radiographs with Ferguson’s views are in the normal range. Her baseline laboratory tests reveal a C-reactive protein (CRP) level of 7.4 mg/dL (reference range: 0.8 mg/dL or less) and a human leukocyte antigen (HLA)-B27 test that is positive. Based on the clinical data presented, which feature of her condition is associated with structural damage related to her inflammatory spondylitis?
A. Elevated CRP level
B. Family history of AS
C. High BASDAI score
D. Positive test for HLA-B27
A. Elevated CRP level
A 75-year-old man with past medical history of diabetes, gout, and hyperlipidemia presents for evaluation of frequent falls in the last few months. He was very active and was an avid gardener until a few years ago when he started having problems standing up after squatting and kneeling. He later developed problems pulling weeds and using some of his gardening tools. In the last year, he has even been having problems picking up small objects, squeezing a toothpaste tube, and other daily activities. His current medications include metformin, colchicine, and atorvastatin. He has not had fever, night sweats, or other constitutional symptoms. He has also been having some dysphagia, but his EGD was normal. Vital signs are in the normal range. The patient walks with a steppage gait and has problems transferring to the examination table. He has some atrophy of the facial muscles, but the extraocular muscles are intact. He also has significant muscle atrophy and weakness in the biceps and quadriceps bilaterally that is worse on the left than on the right. Motor strength is 3+/5 in the proximal upper and lower extremities muscle groups. He has weakness with dorsiflexion of the feet bilaterally and weakness of finger flexion. Reflexes are less than 1+ throughout. Babinski’s reflex is negative.
Laboratory studies are unremarkable with normal creatine phosphokinase and aldolase levels, inflammatory indices, and thyroid function tests.
Muscle biopsy demonstrates a slight decrease in density of myelinated fibers with a preferential loss of large myelinated fibers. Clusters of small regenerated axons and small epineural perivascular lymphocytic infiltrate of CD4+ and CD8+ T cells are observed, but no vasculitic features are noted.
What is the most likely cause of this patient’s muscle weakness and gait abnormalities?
A. Autoimmune necrotizing myopathy (statin-induced)
B. Colchicine toxicity
C. Facioscapulohumeral dystrophy
D. Sporadic inclusion body myositis
D. Sporadic inclusion body myositis
A 32-year-old woman has been recently diagnosed with rheumatoid factor–positive rheumatoid arthritis and started on treatment with methotrexate and etanercept. She is an adjunct professor teaching literature at a local community college. She comes in for a follow-up visit; her arthritis is well controlled on therapy, and she is recommended to obtain influenza, pneumococcal, and COVID-19 vaccinations. She states that she has had no history of any of those infections and would like to avoid vaccination if possible. She has not received vaccinations for influenza in the past.
Which of the following is most predictive of this patient’s current vaccine hesitancy?
a. Disease duration
b. Sex
c. Education level
d. Vaccination history
D) Vaccination history
A 55-year-old man presents with atraumatic left knee pain and swelling. He has been having intermittent symptoms for 8 weeks, which have become persistent for the past 3 weeks. He was evaluated by his PCP 1 week ago, at which time he had laboratory tests and left knee radiographs performed. He currently denies other areas of joint pain. He denies shortness of breath, cough, chest pain, diarrhea, bloody stools, rash, eye pain and redness, fevers, night sweats, and weight loss.
His PMH includes hypertension and degenerative disc disease of the lumbar spine. He also has a history of Lyme disease diagnosed 5 years ago after he presented with erythema migrans (EM) behind his knee, which was discovered by his spouse; no tick was seen. He had fatigue, headache, and myalgias at that time. He was treated with 2 weeks of doxycycline with resolution of his symptoms. He currently takes lisinopril 10 mg daily and acetaminophen PRN. He resides in Minnesota and works outdoors as a land surveyor.
Vital signs are normal. Heart, lung, abdominal, neurologic, and skin examinations are normal. Musculoskeletal examination of the left knee reveals a minimally tender, nonerythematous joint with a large effusion and limited flexion and extension. The remainder of the musculoskeletal examination is normal.
The left knee radiograph from 1 week ago shows a large effusion with normal joint spaces, and no erosions or chondrocalcinosis are seen.
Laboratory results: Albumin 4.2, Alk phos 85, ALT 25, AST 30, anti CCP 8(-), ANA <1:40, Calcium 9.4, CRP 1.5, Creatinine 1.3, ESR 30, Hemoglobin 14.8, WBC 7200, Platelets 325k, RF 14 (-)
Today you aspirate the left knee with removal of 50 mL of yellow, turbid fluid. Synovial fluid analysis reveals a white cell count of 26,500 cells/µL with 81% polymorphonuclear cells, no crystals, and a negative Gram stain and culture. Labs are negative for HLA B27, HIV, HBV & HCV, and IGRA. Urine Chlamydia and gonococcal DNA amplification are negative, and Lyme enzyme-linked immunosorbent assay (ELISA) is highly positive for immunoglobulin G (IgG), and moderately positive for IgM responses. A chest radiograph is obtained and is normal. You suspect a diagnosis of arthritis due to Lyme disease.
Which of the following is the preferred test to confirm the diagnosis for this patient?
a. Joint fluid polymerase chain reaction
b. Serum western blot analysis
c. Synovial tissue culture
d. Urinary antigen test
a) joint fluid PCR
A 59-year-old woman with systemic lupus erythematosus (SLE) is seen in one of your rheumatology clinic’s urgent afternoon slots regarding pain and swelling in her bilateral ankles, knees, and wrists since the morning. In addition to SLE, her past medical history includes crystal-proven gout, hypertension, type 2 diabetes mellitus, and obesity. She has about 1 gout flare per year, most recently 6 months ago, for which she has previously used colchicine with good effect. Her SLE has been complicated in the last 3 months by new onset biopsy-proven nephritis. Current medications include voclosporin 23.7 mg twice daily, mycophenolate mofetil 1 g twice daily, allopurinol 300 mg daily, insulin glargine 15 units daily, lisinopril 10 mg daily, and metformin 500 mg twice daily. On physical examination, she is afebrile, heart rate 94, blood pressure 128/78, body mass index 31kg/m2. There is bilateral swelling and tenderness of the ankles, knees, and wrists. Arthrocentesis of her knee reveals 12,000 leukocytes/μL and intracellular needle-shaped negatively birefringent crystals. Gram stain is negative. Laboratory tests include: ALT 21, AST 18, BUN 20, Creatinine 1.1, CRP 2.4, ESR 32, Hgb A1c 9.8%, WBC 5700, Uric acid 8.2.
Which of the following is the most appropriate dose of colchicine to take today for her current condition?
a) 0.3mg
b) 0.6mg
c) 0.6mg and then 0.3mg 1 hour later
d) 1.2mg and then 0.6mg 1 hour later
0.3mg x 1, then no further colchicine for 3-7 days to avoid colchicine toxicity in setting of voclosporin use
A 38-year-old construction worker presents to the rheumatology clinic for the evaluation of back pain that has been going on intermittently for the past 18 months. Pain extends across the mid and lower back and interrupts his sleep. An epidural injection was performed 3 months ago without relief of his pain. Today, he reports that he has 1 hour of morning stiffness despite taking a 2-week leave from work and daily nonsteroidal antiinflammatory drugs. He has no prior medical history and no significant family history.
On examination, there is no focal midline bony or sacroiliac joint tenderness. The straight-leg raise and FABER test is negative bilaterally. A modified Schober test increases the marked distance by 5 cm during forward flexion.
The patient had laboratory tests done recently with a C-reactive protein level of 12 mg/dL (reference range, ≤0.8 mg/dL). Radiographs of the sacroiliac joints and lumbosacral spine were performed 3 months ago and were normal. You obtain magnetic resonance imaging (MRI) (see attached images, key finding is identified by the arrow, not arrowheads).
Which of the following is the most likely etiology of the patient’s pain?
a. Aseptic discitis
b. Degenerative disc disease
c. Spinal epidural abscess
d. Vertebral osteomyelitis
A. Aseptic discitis
A 62-year-old woman with longstanding discoid lupus presents for evaluation for progressive weakness. She reports that weakness has gotten to a point where it is now difficult for her to walk to her mailbox. She has been on hydroxychloroquine 400 mg daily for the past 20 years for discoid lupus, which has been stable. The diagnosis of discoid lupus was made based on skin biopsy of a lesion on the forearm. She does not have a history of systemic lupus erythematosus. Annual eye examinations have been negative for maculopathy.
She is afebrile on physical examination with a blood pressure of 125/78 mmHg. Her height is 5 ft 4 in and weight is 160 lb. She is in no acute distress and is breathing comfortably on room air. Strength in the proximal lower extremity is 4/5 bilaterally but otherwise normal elsewhere. Chronic discoid lesions are present on the forearms bilaterally. No erythema or rashes are noted on the knuckles, chest, or back. Laboratory results include: ANA negative, antiRNP, negative, antiSmith negative, SSA negative, SSB negative, antiSRP negative, CK 450, WBC 5k, Hgb 11, Platelets 200k.
Electromyography of the left quadriceps muscles reveals increased insertional activity and spontaneous fibrillations consistent with a myopathic process. Magnetic resonance imaging of both thighs shows T2 enhancement of quadriceps muscles bilaterally.
Which of the following muscle biopsy findings would be the most consistent with this patient’s suspected diagnosis?
A. Lysosome-derived cytoplasmic inclusions
B. Necrotic, regenerating muscle fibers
C. Perifascicular inflammation and atrophy
D. Ragged red fibers
E. Rimmed vacuoles
A. Lysosome-derived cytoplasmic inclusions
You are asked to urgently evaluate a 44-year-old woman who experienced the onset of right shoulder pain. The patient reported that 10 days earlier she had a routine vaccination in her right deltoid muscle of her arm. Within 48 hours of the vaccination, she experienced the rapid onset of right shoulder pain. She used over-the-counter naproxen for her pain but had minimal improvement. Several days into the pain, the patient developed significant right upper limb weakness. This made most activities of daily living very challenging. The pain and the weakness prompted her to be evaluated by her primary care provider who then urgently referred her to you.
The patient has no significant past medical history, her review of systems is unremarkable, and she does not smoke. She denies new double vision or neck pain and recent traumatic events to the right shoulder. Vital signs are stable, she is afebrile, and her examination is otherwise unremarkable except for her right shoulder. There is no redness or warmth, but she has substantial weakness noted on active internal and external rotation, abduction, and adduction of the arm at the shoulder. Strength is 3/5 in all affected muscle groups. Active and passive range of motion elicit significant discomfort. Brachioradialis reflex was 1+ on the right but 2+ on the left.
You perform an in-office ultrasound scan of her shoulder, which shows no tendon tears or ruptures, glenohumeral synovitis, or calcifications. You ask your neurology colleague to perform an urgent upper limb nerve conduction study and electromyography, which 1 week later reveals severe axonal denervation of the right deltoid and supraspinatus muscles with mild involvement of the infraspinatus muscle and early evidence of renervation.
What is the etiology for this patient’s shoulder pain?
a. Brachial neuritis
b. Cervical radiculopathy
c. Mononeuritis multiplex
d. Myasthenia gravis
A 59-year-old man with osteoarthritis and hand pain present for a return appointment. He has had 2 years of gradually worsening hand pain that seems to be exacerbated by use and improved by rest. He is physically active and enjoys running. His golfing friend was recently diagnosed with osteoporosis, and he has questions about the disease. He denies personal or family history of fractures and does not smoke or drink alcohol. The patient denies erectile dysfunction. Vital signs are within normal limits, and physical examination reveals Bouchard and Heberden nodes bilaterally without any tenderness, swelling, or inflammatory features.
Relevant laboratory results include: 25-hydroxy Vitamin D 42, Albumin 4.0, Calcium 9.8, Creatinine 1.2, TSH 3.2
At what age should this patient's bone mineral density be first measured?
a) 50
b) 65
c) 70
d) 80
c) 70
A 65-year-old woman with a history of type 2 diabetes and hypertension presents to your office due to concerns about possible gout. She has no current foot or ankle pain or swelling but complains of intermittent sharp pain at the base of both great toes, which is worse with pressure or ambulation for longer than 15 minutes. She denies other joint complaints. She denies history of kidney stones or tophi. She does not smoke cigarettes or drink alcohol. She notes a family history of gout in her father and older brother.Current medications include metformin 500 mg twice daily, dapaglifozin 10 mg daily, candesartan 16mg daily, calcium 500 mg twice daily, vitamin C 250 mg daily, aspirin 81 mg daily, and acetaminophen 325 mg twice daily as needed for joint pain.On physical examination, she has bilateral hallux valgus without synovitis. She has mild tenderness with palpation and range of motion at the first metatarsophalangeal joint bilaterally. There is no synovitis of the ankles or knees and no evidence of olecranon bursitis. There are no tophi. She was recently seen by her primary care provider, and laboratory tests revealed a uric acid level of7.2 mg/dL (reference range, 3.0-7.0 mg/dL) with a serum creatinine of 1.1 mg/dL (reference range,0.5-1.1 mg/dL).Which of the patient’s current medications is most likely to reduce her risk of developing gout?
a) Aspirin
b) Candesartan
c) Dapagliflozin
d) Vitamin D
Dapagliflozin
A 20-year-old man presents to rheumatology clinic with a chief complaint of low back pain. He reports having mild pain for 2 years, especially in the mornings. Over the last week, it has acutely worsened, and he describes it as being severe. He says it is mostly on the left involving his hip and back to where he is limping and can barely walk.
On examination, vital signs include temperature of 98.6 °F (37.0 °C), heart rate of 108 bpm, blood pressure of 108/62 mmHg, pulse oximetry of 98%, and weight of 121 lb (55 kg). There is scarring along his ventral forearms. He appears uncomfortable but not in acute distress. He can flex both hips but has extreme tenderness to palpation of his left sacroiliac (SI) joint with a positive Patrick test on the left.
Laboratory results include:
CRP: 12.4, ESR: 37, HLA B27: Pending, WBC: 13,250, Platelet count: 502k
A MRI of the SI joints can be seen. Which finding on the MRI is the most helpful in diagnosing this patient’s condition?
a. Erosions
b. Iliac-dominant bone marrow edema
c. Joint space enhancement/widening
d. Periarticular muscle edema
D. Periarticular muscle edema
A 57-year-old woman presents to rheumatology clinic with a 1-week history of pain and swelling of her right first metatarsophalangeal (MTP) joint and right knee. She recalls having a similar episode a year ago that resolved with ibuprofen. Her history is notable for diet-controlled type 2 diabetes and obesity. Her only medication is ibuprofen as needed. Her family history is notable for a father who developed gout in his 50s. She does not use tobacco or alcohol. She works as a biochemist at the local university. On physical examination, vital signs are within normal limits except for a body mass index of 32 kg/m2.She is a well-appearing woman in no acute distress. Cardiopulmonary examination is unremarkable. Neurologic examination is normal. On joint examination, there is erythema, swelling, and warmth involving the right first MTP joint and a large right knee effusion. Knee effusion aspiration reveals 14,000 leukocytes/μL and intracellular negatively birefringent needle-shaped crystals. Laboratory tests show: ESR 40, CRP 5, Serum Creatinine 0.9, Uric acid 10.2.
You counsel her regarding the diagnosis, offer ibuprofen for treatment, and recommend follow up in a month. She inquires if there is any research into the underlying cause of her symptoms. Which of the following genes is the most likely to be involved in the pathogenesis of her underlying condition?
a) ATP binding cassette subfamily G member 2(ABCG2)
b) Progressive ankylosis protein homolog (ANKH)
c) Hypoxanthine-guanine phosphoribosyltransferase (HGPRT)
d) Phosphoribosylpyrophosphate synthetase (PRPS)
ATP binding cassette subfamily G member 2(ABCG2)
A 26-year-old woman presents to the rheumatology clinic with low back pain of six months’ duration that has impacted her ability to train for her third marathon. She experiences about 15 minutes of morning stiffness each day. This back pain worsens with activity but is somewhat improved with nonsteroidal antiinflammatory drugs; she has not tried physical therapy. She has no past medical history and no family history of spondyloarthritis, inflammatory bowel disease, uveitis, or psoriasis.
Physical examination findings include no synovitis, dactylitis, or enthesitis. She has no skin findings of psoriasis. She has normal spinal metrology including occiput-to-wall, lateral spinal flexion, and modified Schober measures.
Diagnostic studies include an erythrocyte sedimentation rate of 12 mm/hr (reference range, <20 mm/hr) and C-reactive protein level of 0.6 mg/dL (reference range, ≤0.8 mg/dL). She is human leukocyte antigen B27 negative. Results of radiography and magnetic resonance imaging (MRI) of the pelvis are shown below.
Radiograph of the sacroiliac joints, posteroanterior view, can be seen. What treatment option should be offered to this patient?
a. Adalimumab
b. Massage therapy
c. Physical therapy
d. Secukinumab
C. Physical therapy