Mock Rheumatology Module 3

A 35-year-old man presents with a 6-month history of progressive proximal muscle weakness and a violaceous rash over his eyelids, nose, and knuckles.

He reports dysphagia and a 7 kg weight loss over 3 months.

Examination reveals a heliotrope rash, Gottron’s papules, and a V-sign rash on the chest.

Which of the following nail-fold manifestations is most characteristic of dermatomyositis?

A 32-year-old man presents with recurrent painful oral and genital ulcers and blurred vision. He reports recurrent painful red eyes and arthritis of the knees and ankles. There is no relevant family, travel, or sexual-risk history.

Examination reveals shallow buccal and scrotal ulcers, and ophthalmology confirms uveitis.

What is the most likely diagnosis?

The following cells are predominantly found in RA synovial tissue, EXCEPT:

Which of the following cytokines is NOT of key importance in the pathogenesis of rheumatoid arthritis?

Bony erosion in rheumatoid arthritis is typically mediated by which cell?

The following are required to support osteoclast development in RA, EXCEPT:

Which one of the following conditions causes high titres of rheumatoid factor?

Which of the following is the most common cause of a false-positive rheumatoid factor in the general population?

An asymptomatic individual is found to be anti-CCP positive.

What is the biggest modifiable risk factor for the future development of RA?

A 48-year-old woman presents to the rheumatology clinic with a 5-month history of symmetrical polyarthritis affecting the small joints of her hands, wrists, and feet.

She describes early morning stiffness lasting approximately 90 minutes and increasing difficulty with fine motor tasks at work.

On examination, she has synovitis of multiple metacarpophalangeal and proximal interphalangeal joints, with a swollen joint count of 12 and a tender joint count of 14.

Investigations reveal:

• Rheumatoid factor: 180 IU/mL (normal <14 IU/mL) — high titre
• Anti-cyclic citrullinated peptide (anti-CCP) antibody: strongly positive at 240 U/mL (normal <20 U/mL)
• ESR: 58 mm/hr (normal <20 mm/hr)
• CRP: 42 mg/L (normal <5 mg/L)
• Hand and foot radiographs: early marginal erosions at the second and third metacarpophalangeal joints bilaterally

When counselling this patient regarding prognosis, all of the following are recognised predictors of rheumatoid arthritis severity, EXCEPT:

A 62-year-old woman with stable RA on oral methotrexate 10 mg/week for 18 months presents with 3 weeks of progressive breathlessness and non-productive cough.

She is tachypnoeic with SpO₂ 92% on room air and bibasal fine crackles.

Investigations:

• HRCT shows patchy ground-glass attenuation and small consolidations in the lower zones.
• PFTs show a restrictive pattern with reduced DLCO.
• Peripheral eosinophilia is present.
• Cultures and viral serology are negative.
• BAL shows lymphocytic predominance with increased CD4 lymphocytes.

In addition to stopping methotrexate, which intervention is most useful?

A 45-year-old New Zealand-born woman with a long history of seropositive rheumatoid arthritis attends the rheumatology clinic with persistently active disease.

Despite optimised treatment with methotrexate and hydroxychloroquine, she has ongoing synovitis, elevated inflammatory markers, and early erosive changes on imaging.

Her rheumatologist plans to escalate treatment by commencing infliximab, a TNF-alpha inhibitor.

As part of the mandatory pre-biologic screening, she undergoes an interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) and the result returns positive.

Her chest radiograph is normal.

She is entirely asymptomatic and reports no cough, fevers, night sweats, or weight loss.

She has no history of prior active TB or previous TB treatment.

What should be done prior to commencing infliximab?

What is the mechanism of action of rituximab?

All of the following are targets of DMARD therapy in rheumatoid arthritis, EXCEPT:

You are the rheumatology registrar reviewing five patients with rheumatoid arthritis in a busy outpatient clinic.

The consultant asks you to identify which patients meet the criteria for escalation to a biologic disease-modifying antirheumatic drug (bDMARD), in line with contemporary treat-to-target principles and Australian PBS prescribing requirements.

Patient 1: A 54-year-old man with seropositive rheumatoid arthritis has been treated with methotrexate and sulfasalazine at maximally tolerated doses for 6 months. Despite good adherence, he continues to have a persistently high swollen joint count of 10 on repeated assessments, with ongoing morning stiffness and functional limitation.

Patient 2: A 61-year-old woman with established rheumatoid arthritis has trialled methotrexate, leflunomide, and hydroxychloroquine in combination. Although her joint counts have improved modestly, her inflammatory markers remain persistently elevated, with an ESR of 62 mm/hr (normal <20 mm/hr) and CRP of 48 mg/L (normal <5 mg/L), indicating ongoing active disease.

Patient 3: A 39-year-old woman with seropositive rheumatoid arthritis was commenced on methotrexate but developed significant hepatotoxicity, and subsequently experienced severe gastrointestinal intolerance with leflunomide and a rash with sulfasalazine. She has been unable to tolerate conventional synthetic DMARDs despite appropriate dose adjustments and supportive measures.

Patient 4: A 47-year-old man with anti-CCP-positive rheumatoid arthritis has completed an adequate trial of at least two conventional synthetic DMARDs, including methotrexate at target dose for the required duration, but has had an inadequate response with persistent moderate-to-high disease activity on validated disease activity scoring.

Patient 5: A 58-year-old woman with rheumatoid arthritis of 5 years’ duration is well controlled on methotrexate monotherapy. She has no radiographic erosions, a swollen joint count of 0, a tender joint count of 1, normal inflammatory markers, and a DAS28 score consistent with low disease activity. She is asymptomatic and functioning normally.

Which of the following patients should NOT be considered for biologic DMARD therapy?

A 47-year-old man presents to the Emergency Department with a complaint of shortness of breath. He has a notable medical history of chronic sinusitis, which has been recurrent and difficult to manage. On examination, he appears fatigued and reports a recent unintentional weight loss. He also mentions occasional haemoptysis and a persistent dry cough over the past few weeks.

Initial investigations reveal the following:

• Hemoglobin (Hb): 104 g/L (indicating mild anemia)
• Platelet count: 477 x 10^9/L (thrombocytosis)
• White Cell Count (WCC): 14.3 x 10^9/L (leukocytosis)
• Erythrocyte Sedimentation Rate (ESR): 92 mm/h (significantly elevated)
• Urea: 20 mmol/L (elevated)
• Creatinine: 198 µmol/L (elevated, indicating renal impairment)
• Urine dipstick: Blood +++ (indicating haematuria)

Based on the clinical presentation and laboratory findings, which of the following is the most likely diagnosis?

Which of the following features is NOT typically seen in adult-onset Still’s disease?

A 34-year-old woman presents to the dermatology clinic with a 12-month history of persistent, disfiguring skin lesions affecting her face and scalp.

She reports that the lesions worsen following sun exposure, particularly after a recent beach holiday.

On examination, there are well-demarcated, erythematous, scaly plaques over her cheeks, nose, and external ears.

Several lesions on her scalp have progressed to areas of permanent hair loss with scarring, atrophy, and central depigmentation surrounded by a hyperpigmented rim. The affected skin feels indurated, and adherent scale is noted overlying the plaques.

A skin biopsy is performed. Histopathology demonstrates hyperkeratosis, follicular keratin plugging, an interface dermatitis with basal vacuolar change, and a perivascular and periadnexal lymphocytic infiltrate.

Screening investigations, including antinuclear antibody (ANA), anti-dsDNA, full blood count, renal function, and urinalysis, are unremarkable, and she has no systemic symptoms.

Which one of the following statements is correct concerning this patient’s condition?

Which one of the following is the most common ocular manifestation of rheumatoid arthritis?

Each of the following may be seen in reactive arthritis, EXCEPT:

A 52-year-old woman presents with a 3-month history of progressive proximal muscle weakness, describing increasing difficulty rising from a chair, climbing stairs, and lifting objects above her head.

She also reports fatigue and a violaceous rash over her eyelids and the extensor surfaces of her knuckles.

On examination, there is symmetrical proximal muscle weakness affecting the shoulder and hip girdles.

Cutaneous findings include a heliotrope rash over the upper eyelids and raised violaceous papules over the metacarpophalangeal and interphalangeal joints (Gottron’s papules).

Investigations reveal:

• Creatine kinase: 4,200 U/L (normal 30–150 U/L)
• Positive antinuclear antibody
• Positive anti-Mi-2 antibody

A diagnosis of dermatomyositis is suspected. 

Which imaging modality is most useful to guide the site of muscle biopsy in this patient?

A 28-year-old woman with an established diagnosis of systemic lupus erythematosus (SLE) presents to the rheumatology clinic for review. She reports increasing fatigue, new joint pains affecting her hands and wrists, and mild facial swelling over the past three weeks.

On examination, she has a malar rash, mild synovitis of the metacarpophalangeal joints, and trace peripheral oedema.

Urinalysis reveals proteinuria and red cell casts, raising concern for a lupus flare with possible renal involvement.

Investigations:

• Antinuclear antibody (ANA): strongly positive (as at diagnosis)
• Anti-dsDNA: Rising titres.
• Extractable nuclear antigen antibodies (ENA): positive anti-Ro
• C-reactive protein: 4 mg/L (normal <5 mg/L)
• Haemoglobin: 108 g/L (normal 115–165 g/L)
• C3/C4 level: Low

Which of the following is most useful for assessing disease activity in this patient with systemic lupus erythematosus?

A 32-year-old woman with recently diagnosed adult-onset Still’s disease on immunosuppression presents with 2 weeks of high fever, fatigue, 5 kg weight loss, and a maculopapular rash.

Examination reveals hepatosplenomegaly, generalised lymphadenopathy, and new progressive confusion.

Investigations:

• Ferritin >5000 µg/L (30–300) with transaminitis liver function test.
• Platelets 70 × 10⁹/L (150–400)
• WCC 12 × 10⁹/L (falling from previously higher),
• ESR 30 mm/h (unexpectedly low)
• Triglycerides 400 mg/dL (4.5 mmol/L).

What should be the next step in investigation?

A 56-year-old man presents with a 4-month history of painless bilateral parotid swelling, dry eyes, mild dysphagia, and 10 kg of unintentional weight loss. He denies fevers, night sweats, or preceding infection.

On examination, he is mildly jaundiced with bilaterally enlarged, firm, non-tender parotid glands. There is no cervical, axillary, or inguinal lymphadenopathy, and no hepatosplenomegaly.

Investigations reveal:

• Bilirubin: mildly elevated at 32 µmol/L (normal <20 µmol/L)
• Alkaline phosphatase (ALP): elevated at 210 U/L (normal 30–110 U/L)
• Serum IgG4: 3.2 g/L (normal 0.03–1.35 g/L)
• White cell count: normal at 6.5 × 10⁹/L (normal 4.0–11.0 × 10⁹/L)
• Haemoglobin: normal at 142 g/L (normal 130–180 g/L)

Abdominal ultrasound shows a “sausage-shaped” pancreas with dilated intrahepatic bile ducts.

MRI confirms diffuse pancreatic enlargement with a featureless “capsule-like” rim and distal common bile duct narrowing.

Neck and chest CT demonstrate bilateral parotid enlargement without lymphadenopathy.

What is the most appropriate initial treatment for this patient?

A 45-year-old man presents with 6 months of intermittent right-predominant ear pain and reddish-purple auricular discolouration sparing the earlobes, with intermittent hearing loss and tinnitus, two episodes of fever and malaise, and mild wrist and knee arthralgia.

He denies nasal, ocular, or respiratory symptoms, but recalls unexplained chest pain a year ago.

What is the most likely diagnosis?

A 72-year-old man presents with 2 months of symmetric polyarthritis with marked pitting oedema over the dorsum of both hands and feet, and morning stiffness lasting under an hour. He denies weight loss, fever, or malaise.

Examination shows tender, swollen MCP and PIP joints without warmth or erythema.

Inflammatory markers are normal and rheumatoid factor is negative.

What is the most likely diagnosis?

A 54-year-old Thai man was seen in the rheumatology clinic 3 weeks ago with a 2-year history of recurrent acute gout and a serum urate of 540 µmol/L (8.9 mg/dL). He has a background of hypertension and stage 3 chronic kidney disease (eGFR 52 mL/min/1.73m²). He was started on allopurinol 100 mg daily without any pre-treatment investigations.

He now presents to the emergency department with a 3-day history of fever, malaise, and a rapidly spreading painful rash. On examination, he is febrile at 38.9°C. There are widespread dusky erythematous macules with early blistering over his trunk and face, and painful erosions of the oral and conjunctival mucosa. Nikolsky’s sign is positive, with epidermal detachment affecting approximately 8% of his body surface area.

His allopurinol is stopped immediately, and he is transferred to a burns unit for supportive care.

Which of the following investigations, if performed before starting his urate-lowering therapy, would most likely have prevented this presentation?

A 15-year-old boy presents with a 4-month history of low back pain and right heel pain that is worse in the mornings with stiffness lasting over an hour, improving with activity. He also reports intermittent swelling of the right knee.

On examination, there is tenderness over the right Achilles insertion, reduced lumbar spine flexion, and a swollen right knee with effusion.

He has a positive family history of ankylosing spondylitis in his father.

Investigations reveal:

• Haemoglobin 132 g/L (130–170)
• Platelets 410 ×10⁹/L (150–400)
• Erythrocyte sedimentation rate 40 mm/hr (<15)
• C-reactive protein 18 mg/L (<5)
• Antinuclear antibody negative
• Rheumatoid factor negative
• HLA-B27 positive

Which of the following is the most appropriate first-line pharmacological management for this patient?