Mock Rheumatology Module 5

A 26-year-old man is referred with a 19-month history of insidious-onset low back pain and prolonged early-morning stiffness that improves with activity and wakes him in the second half of the night. He also reports intermittent swelling of the left knee and posterior heel pain.

Examination demonstrates a modified Schober test of 2.5 cm and chest expansion of 2 cm. He is HLA-B27 positive with a CRP of 26 mg/L (reference <5 mg/L).

MRI of the sacroiliac joints shows bone-marrow oedema consistent with active sacroiliitis.

Despite maximal-dose naproxen for two separate four-week periods and a supervised exercise programme, his BASDAI remains 6.8.

What is the most appropriate next pharmacological therapy?

A 34-year-old man with established HLA-B27-positive ankylosing spondylitis has predominantly axial symptoms with limited spinal mobility and no significant peripheral joint involvement. He is reviewing his management options.

Which of the following interventions is least likely to benefit his axial disease?

A 40-year-old woman with active ankylosing spondylitis commences etanercept after inadequate response to NSAIDs. She asks what benefits she can expect over the first two years of therapy.

Which of the following outcomes is least likely to be demonstrable within this short treatment period?

A 45-year-old man with a 20-year history of ankylosing spondylitis is being assessed for suitability for a TNF inhibitor. His clinicians wish to estimate his likelihood of a favourable response.

Which of the following is NOT associated with a good response to TNF inhibitors in ankylosing spondylitis?

A 48-year-old man with a 10-year history of plaque psoriasis presents with pain and deformity of the fingers. Examination shows dactylitis of the third right finger and nail pitting.

A hand radiograph demonstrates a “pencil-in-cup” appearance at the distal interphalangeal joints with adjacent bony proliferation.

What is the most likely underlying diagnosis?

A 52-year-old woman with polyarticular psoriatic arthritis has progressive joint damage on serial radiographs despite methotrexate. She is concerned about further structural deterioration.

Which of the following therapies has the strongest evidence for inhibiting radiographic progression in psoriatic arthritis?

A 24-year-old man with a 6-year history of ankylosing spondylitis is reviewed in the rheumatology clinic. His axial disease has been inadequately controlled on maximal NSAID therapy, and his rheumatologist is planning to commence a biologic agent.

He has no personal history of gastrointestinal symptoms, but his older sister was recently diagnosed with Crohn’s disease. His current investigations show:

• CRP 28 mg/L (<5)
• ESR 34 mm/hr (<15)
• HLA-B27 positive
• Faecal calprotectin 180 µg/g (<50)

Which of the following biologic agents should be avoided in this patient?

A 40-year-old woman, para 3, presents with a 12-month history of dull low back and buttock pain without inflammatory features. She is systemically well with normal inflammatory markers and is HLA-B27 negative.

A pelvic radiograph shows bilateral, symmetrical, triangular sclerosis confined to the iliac side of both sacroiliac joints, with preserved joint spaces and no erosions.

What is the most likely diagnosis?

A 30-year-old woman with SLE presents with acute kidney injury and severe hypertension (200/96 mmHg).

Her history includes deep venous thrombosis and pulmonary embolism, and three first-trimester miscarriages; she takes hydroxychloroquine.

Investigations:

• Haemoglobin 123 g/L (reference 115–160),
• Platelets 122 ×10⁹/L (reference 150–400),
• Creatinine 244 µmol/L (reference 45–90),
• Normal C3 and C4,
• ANA 1:1280,
• Anti-dsDNA negative
• Anticardiolipin IgG and IgM both >100 U/mL
• Lupus anticoagulant positive
• Direct antiglobulin test negative
• Rare schistocytes on film.
• Renal biopsy shows intracapillary fibrin thrombi consistent with thrombotic microangiopathy, with immunofluorescence demonstrating fibrin only and no immunoglobulin or complement deposition.

What is the most likely diagnosis?

A 20-year-old woman presents with a two-week history of tender, red, nodular lesions over both shins.

Her history includes recurrent painful oral aphthous ulcers, vulvar ulcers negative for herpes simplex virus, and an episode of anterior uveitis treated with topical prednisone. Naproxen has not relieved her symptoms.

Examination shows two tongue ulcers and several tender subcutaneous nodules resembling erythema nodosum, with no synovitis.

Investigations:

• ESR 95 mm/h (reference <20)
• Normal full blood count 
• Metabolic panel: negative rheumatoid factor,  ANA and ANCA
• Normal urinalysis and chest radiograph

Which of the following is the most appropriate first-line agent to treat her mucocutaneous manifestations?

A 49-year-old man with long-standing asthma and recurrent pulmonary infiltrates presents with worsening wheeze, low-grade fever, palpable purpura over both legs, and a new left foot-drop.

Investigations:

• WCC 18.0 ×10⁹/L with eosinophils 3.6 ×10⁹/L (reference <0.5).
• IgE 1250 IU/mL.
• ANCA pending.

He has commenced intravenous methylprednisone.

Which is the most appropriate additional therapy?

A 16-year-old girl presents with a six-month history of cold-induced triphasic colour change (white, then blue, then red) affecting her fingers, with associated pain on rewarming.

She is otherwise well and well-grown, with normal peripheral pulses.

On a warm day her fingers appear slightly puffy without ulceration or trophic change.

Nailfold capillaroscopy shows enlarged and distorted capillary loops. General measures alone have been insufficient.

Besides cold avoidance, which is the most appropriate pharmacological therapy?

A 38-year-old woman presents with a 12-month history of colour changes in her fingers on cold exposure, progressing through white, blue and red phases with associated pain.

She reports mild puffiness of her fingers but denies skin tightening, dysphagia, dyspnoea or arthralgia.

Examination confirms no sclerodactyly, no digital ulcers and no telangiectasia.

Nail fold capillaroscopy demonstrates giant capillaries, capillary haemorrhages and areas of avascularity.

Investigations:

• Full blood count and metabolic panel normal.
• ANA positive at 1:640 (nucleolar pattern).
• Anti-centromere and Anti-Scl-70 antibodies pending.

Which of the following is the most likely outcome for this patient?

A 54-year-old woman with a 10-year history of primary Sjögren’s syndrome presents with a three-month history of progressive, persistent swelling of the left parotid gland.

She reports longstanding dry eyes and dry mouth.

On examination there is a firm, non-tender, unilateral parotid mass with no overlying skin change and no facial nerve involvement. She has palpable cervical lymphadenopathy.

Investigations:

• Full blood count normal
• ESR 40 mm/h (reference <20)
• Positive anti-Ro (SSA) and anti-La (SSB)
• Rheumatoid factor strongly positive
• Low serum C4.
• Serum protein electrophoresis reveals a monoclonal IgM band.

Compared with baseline, her previously elevated rheumatoid factor titre has now fallen and cryoglobulins have become undetectable. A parotid biopsy is performed.

Which of the following is the most likely histological subtype of lymphoma in this patient?

A 42-year-old woman is reviewed in the rheumatology clinic. Five years ago she was diagnosed with mixed connective tissue disease characterised by Raynaud phenomenon, puffy hands, arthralgia, myositis and oesophageal dysmotility, with a very high titre anti-U1 ribonucleoprotein (anti-U1 RNP) antibody.

She currently feels well and has no cardiorespiratory symptoms. Examination is unremarkable with normal heart sounds, no oedema and clear lung fields.

Investigations: full blood count and metabolic panel normal, ANA positive at 1:2560 (speckled), anti-U1 RNP strongly positive, anti-Scl-70 and anti-centromere negative.

Which of the following is the most appropriate ongoing surveillance strategy to detect the cardiopulmonary complication that carries the greatest mortality risk in her condition?

A 62-year-old woman with type 2 diabetes, hypothyroidism and prior stroke presents with worsening left shoulder pain, which deteriorated after recent pacemaker insertion for sick sinus syndrome.

She has a background of rotator-cuff tendinitis managed conservatively.

On examination she cannot abduct the left shoulder beyond 90° actively or passively, and neither active nor passive range improves after injection of lidocaine into the subacromial bursa.

What is the most appropriate next investigation?

A 30-year-old competitive tennis player presents with a three-month history of right shoulder pain, worse with overhead activity and at night, radiating to the mid-upper arm.

Examination reveals a painful arc on abduction between 60° and 120°, full passive range, and a negative drop-arm test. Conservative measures have failed and he is reluctant to take NSAIDs. A corticosteroid injection is planned.

Injection into which site is most likely to achieve the best outcome?

A 60-year-old man with treated hypothyroidism presents with a one-month history of bilateral lower-leg discomfort, relieved by elevating his legs on pillows. He stopped his levothyroxine two weeks ago.

Examination shows mild warmth, 1+ pitting oedema and tibial tenderness.

Investigations: WCC 11.3 ×10⁹/L, ESR 46 mm/h (reference <20).

Radiographs show mild soft-tissue swelling and periosteal new bone formation along the tibiae.

What is the best next step in management?

A 32-year-old woman presents with bilateral hand and wrist stiffness and pain, and is found to have splenomegaly.

Investigations: neutrophils 1.3 ×10⁹/L (reference 2.0–7.5), positive rheumatoid factor and positive anti-SSA (anti-Ro) antibodies.

Which complication is this patient most likely to develop?

A 32-year-old woman presents with central chest pain due to a myocardial infarction. Her history includes post-prandial abdominal pain, peripheral vascular disease and recently diagnosed hypertension that is difficult to control.

Investigations: normal full blood count, creatinine 200 µmol/L (reference 45–90) and positive ANA.

What is the most useful next diagnostic test?

A 62-year-old man presents with a 4-month history of progressive proximal muscle weakness affecting his ability to climb stairs and rise from a chair.

He was commenced on atorvastatin 40 mg 18 months ago for primary cardiovascular prevention.

Atorvastatin was ceased by his general practitioner 3 months ago without improvement.

Examination reveals MRC grade 3/5 power in bilateral hip flexors and shoulder abduction.

His creatine kinase is 8,400 U/L (reference range: 30–200 U/L).

Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibodies are strongly positive.

Muscle biopsy demonstrates prominent myofibre necrosis with minimal inflammatory infiltrate and MHC class I upregulation.

Electromyography shows an irritable myopathy.

Which of the following is the most appropriate initial treatment strategy?

A 58-year-old woman presents to the emergency department with acute onset pain, swelling, and erythema of her right first metatarsophalangeal joint over the past 18 hours.

She has a background of hypertension, type 2 diabetes mellitus, and chronic kidney disease stage 3a (eGFR 52 mL/min/1.73m²).

Her regular medications include atorvastatin 40mg daily, irbesartan 300 mg daily, amlodipine 10 mg daily, metformin 500 mg twice daily, and empagliflozin 10 mg daily.

On examination, the joint is exquisitely tender, warm, and swollen.

Her serum uric acid level is 0.18 mmol/L (reference range: 0.15–0.40 mmol/L for females), CRP is 185 mg/L (reference range: <5 mg/L), and white cell count is 13.2 × 10⁹/L (reference range: 4.0–11.0 × 10⁹/L).

Joint aspiration reveals negatively birefringent monosodium urate crystals under polarised light microscopy. 

Which of the following medications is most likely responsible for the misleadingly low serum uric acid level?

A 55-year-old man with gout is being assessed for commencement of urate-lowering therapy.

Which of the following is the strongest indication to start allopurinol?

A 54-year-old man with end-stage kidney disease secondary to IgA nephropathy receives a deceased donor renal transplant. His post-transplant course is uncomplicated, and he is commenced on a standard triple immunosuppressive regimen comprising tacrolimus, mycophenolate mofetil, and prednisone.

His background history is significant for severe tophaceous gout, which was previously managed with allopurinol 100 mg daily while on haemodialysis.

Post-transplant, his serum uric acid rises to 0.58 mmol/L (reference range: 0.20–0.43 mmol/L for males) and he experiences recurrent gout flares.

He is also noted to be leucopenic on a routine blood count and have been experiencing some gastrointestinal side effects including nausea and intermittent diarrhoea.

The transplant team decides that long-term urate-lowering therapy with allopurinol is necessary. However, they are concerned about a critical drug interaction with one of his immunosuppressive medications.

Which of the following immunosuppressive agents should be substituted to safely allow the concurrent use of allopurinol in this patient?

A 48-year-old man presents to his general practitioner for review following a second episode of acute gout affecting his right first metatarsophalangeal joint.

His serum uric acid is 0.54 mmol/L (reference range: 0.20–0.43 mmol/L for males).

His BMI is 31 kg/m² and he consumes approximately 20 standard drinks of beer per week.

He is commenced on colchicine for flare prophylaxis and referred to a dietitian for dietary counselling.

He is keen to understand which foods contribute to his hyperuricaemia and asks specifically whether he needs to restrict all purine-containing foods.

He reports that his current diet includes regular consumption of beer, shellfish, red meat, processed meats including bacon, and large quantities of vegetables including spinach, mushrooms, asparagus, and cauliflower.

Which of the following dietary factors is least likely to contribute to hyperuricaemia?

A 52-year-old man presents to the emergency department at 3 am with excruciating pain, swelling, and erythema of his right first metatarsophalangeal (MTP) joint that began suddenly several hours after a large dinner with alcohol consumption.

He has no prior history of joint disease.

His serum uric acid is 0.56 mmol/L (reference range: 0.20–0.43 mmol/L for males) and joint aspiration confirms negatively birefringent monosodium urate crystals.

The emergency physician explains that the first MTP joint is the most common site for initial gout attacks, a phenomenon termed podagra, occurring in approximately 50–70% of first presentations.

Which of the following is the primary pathophysiological mechanism that best explains the predilection of monosodium urate crystal deposition in the first metatarsophalangeal joint?

A 63-year-old man of Han Chinese descent presents to the rheumatology clinic for management of recurrent gout.

He has experienced five flares in the past 12 months despite dietary modification and has palpable tophi over both olecranon bursae.

His background includes hypertension, chronic kidney disease stage 3b (eGFR 38 mL/min/1.73m²), and no history of cardiovascular disease.

His serum uric acid is 0.62 mmol/L (reference range: 0.20–0.43 mmol/L for males) and creatinine is 156 μmol/L (reference range: 60–110 μmol/L).

The treating rheumatologist plans to commence urate-lowering therapy.  

Which of the following is the most appropriate urate-lowering therapy for this patient?

A rheumatology trainee is reviewing a data-driven reclassification of idiopathic inflammatory myopathies into four clusters based on clinical phenotype and myositis-specific autoantibodies.

Which cluster contains the highest frequency of inclusion body myositis?

A 50-year-old man with rheumatoid arthritis on methotrexate presents six weeks after an uncomplicated left total knee replacement with a three-day history of increasing pain, swelling, warmth and erythema of that knee. His other joints are quiescent.

Examination: temperature 37.9°C, heart rate 87/min, blood pressure 136/84 mmHg, and a moderate warm, tender effusion of the left knee with painful restriction of movement.

Investigations:

• Normal renal, liver and haematological indices
• WCC 11.2 ×10⁹/L (reference 4.5–11.0)
• ESR 52 mm/h
• CRP 67 mg/L (reference <5).

What is the most appropriate next step in management?

A 74-year-old woman presents to the emergency department with a 2-week history of new-onset left-sided temporal headache, jaw claudication when eating, and scalp tenderness when brushing her hair.

She also reports 4 weeks of malaise, anorexia, and unintentional weight loss of 3 kg.

Over the past 24 hours, she has experienced two episodes of transient visual blurring in her left eye, each lasting approximately 5 minutes.

On examination, her left temporal artery is thickened, tender, and has reduced pulsation. Visual acuity and fundoscopy are currently normal.

Her investigations reveal:

• ESR 86 mm/hr (reference range: <30 mm/hr for age >50 years)
• CRP 94 mg/L (reference range: <5 mg/L)
• Haemoglobin 108 g/L (reference range: 115–160 g/L for females)
• Platelets 456 × 10⁹/L (reference range: 150–400 × 10⁹/L)

High-dose prednisone is commenced immediately due to the threat of irreversible visual loss. The treating team now needs to confirm the diagnosis.

Which of the following is the most appropriate initial investigation to confirm the diagnosis?