Mock Rheumatology Module 1

Leflunomide is an effective disease-modifying antirheumatic drug for patients with moderate to severe rheumatoid or psoriatic arthritis.

However, it carries several adverse effects such as diarrhoea, mouth ulcers, hepatotoxicity and skin rash.

Which of the following factors is least likely to increase the risk of an adverse reaction with leflunomide?

What is the best method of distinguishing between primary and secondary Raynaud’s phenomenon?

Which of the following pairs of serum markers has the strongest association with disease activity in both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR)?

Secukinumab is an anti–interleukin-17A monoclonal antibody that is useful in which of the following conditions?

Febuxostat is a potent, non-purine, selective inhibitor of xanthine oxidase. Although it shares a mechanism of action with allopurinol, febuxostat is considered a more potent xanthine oxidase inhibitor.

Which of the following best explains this?

A 24-year-old man presents with a history of three episodes of low back pain over five months, each lasting around ten days. The pain improves with exercise and is worse at rest, with associated early-morning stiffness.

Investigations show: full blood examination normal; ESR 19 mm/h [<20]; HLA-B27 positive; plain radiographs of the lumbosacral spine and sacroiliac joints normal.

What is the most likely diagnosis?

A 46-year-old woman is referred to the rheumatology clinic with a six-week history of progressive proximal muscle weakness, difficulty rising from a chair and climbing stairs, and a photodistributed violaceous rash.

On examination she has a heliotrope discolouration of the eyelids, Gottron’s papules over the metacarpophalangeal and proximal interphalangeal joints, and periungual erythema with dilated nailfold capillary loops.

She reports symmetrical pain and morning stiffness in the small joints of both hands, and there is mild synovitis of the metacarpophalangeal and wrist joints on palpation.

Investigations reveal a creatine kinase of 1,240 U/L [30–150], a positive ANA at 1:1280, and a positive anti-Mi-2 antibody.

Plain radiographs of both hands are requested as part of the assessment.

Which of the following findings would be inconsistent with the diagnosis of dermatomyositis?

Which of the following factors is directly involved in the breakdown of cartilage matrix in osteoarthritis?

Which of the following biological agents is of proven benefit in patients with relapsing or refractory giant cell arteritis (GCA)?

An elderly man presents with insidious, painless muscle weakness.

On examination the weakness is asymmetric and involves both distal (finger flexors) and proximal (quadriceps) muscles.

His serum creatine kinase is normal to mildly elevated.

What is the most likely diagnosis?

An 83-year-old man has osteoarthritis of the knee limiting mobility to under 300 m on flat ground. Paracetamol gives minimal relief.

Examination reveals a varus deformity and a warm effusion. His GP commenced naproxen 500 mg twice daily.

Four weeks later his knee has not improved and his serum creatinine has risen from 140 µmol/L to 350 µmol/L [60–110].

In addition to stopping naproxen, which is the most appropriate next step in managing his knee osteoarthritis?

Which clinical feature best differentiates inclusion body myositis from polymyositis?

A 70-year-old man presents with a 5-day history of severe pain and swelling of the left knee. He takes gliclazide (diabetes), cilazapril (hypertension) and aspirin. He has chronic kidney disease with a baseline creatinine of 170 µmol/L [60–110].

On examination he is afebrile with normal vital signs, cannot bear weight, and the knee is swollen, warm and painful with restricted movement. There are no tophi.

Bloods:

• leukocytes 15.6 × 10⁹/L [4.0–11.0] (90% neutrophils)
• random glucose 11.7 mmol/L
• creatinine 167.9 µmol/L
• serum urate 0.63 mmol/L [0.20–0.42]

Urinalysis normal.

Synovial fluid:

• leukocytes 24,000/µL (90% neutrophils).
• polarised light microscopy shows negatively birefringent intra- and extracellular monosodium urate crystals.
• Gram stain negative.

Which is the most appropriate treatment?

Which of the following risk factors predominantly causes hyperuricaemia through reduced renal urate excretion?

Microscopic polyangiitis is most strongly associated with which of the following antibodies?

A 40-year-old woman presents with a six-week history of exertional dyspnoea and a two-week history of progressive muscle weakness.

She reports six months of symmetrical polyarthralgia of the hands, wrists and knees, and recent-onset Raynaud’s phenomenon.

Examination reveals proximal muscle weakness and hyperkeratotic, fissured skin over the palmar and lateral surfaces of the fingers (“mechanic’s hands”).

Investigations:

• Creatine kinase 890 U/L [30–150]
• HRCT chest shows widespread interstitial infiltrates
• ANA 1:2560 speckled
• Anti-Jo-1 positive
• Anti-dsDNA negative.

What is the most likely diagnosis?

Which of the following is a mandatory criterion for the diagnosis of polymyalgia rheumatica?

Dermatomyositis is associated with an increased risk of underlying malignancy.

In what time frame from diagnosis is the risk of associated malignancy greatest?

Which of the following is the strongest identified risk factor for developing systemic sclerosis?

Which of the following is least consistent with limited cutaneous systemic sclerosis?

Limited cutaneous systemic sclerosis is most closely associated with which antibody?

Diffuse cutaneous systemic sclerosis is most closely associated with which antibody?

Which of the following is most characteristic of diffuse cutaneous systemic sclerosis?

Which antibody is most associated with scleroderma renal crisis in diffuse cutaneous systemic sclerosis?

Which of the following is NOT associated with an increased risk of interstitial lung disease in systemic sclerosis?

What is the most common histopathological pattern of interstitial lung disease in systemic sclerosis?

What is the most common gastrointestinal manifestation of systemic sclerosis?

In IgG4-Related Disease, which of the following is NOT considered an exclusion criterion?

A 62-year-old woman with gout and hypertension requires optimisation of her antihypertensive regimen. Given recurrent gout flares, you wish to choose an agent that may also lower serum urate.

Which of the following has a uricosuric (urate-lowering) effect that may be beneficial?

A 54-year-old woman presents to the rheumatology clinic for review of several recently diagnosed connective tissue disorders across a busy outpatient service.

As part of a departmental quality initiative, the team is reviewing which patients warrant baseline screening for interstitial lung disease (ILD) with high-resolution computed tomography (HRCT) and pulmonary function testing (PFTs), even in the absence of respiratory symptoms.

The following five patients are discussed. All are newly diagnosed, asymptomatic from a respiratory standpoint, and have normal resting oxygen saturations.

For which of the following patients is routine baseline screening for ILD generally NOT recommended, owing to the low prevalence of clinically significant ILD in this condition?