MRCP Part 1 Rheumatology 2 — Questions and Answers
Question 1: A 74-year-old woman presents with 6 weeks of bilateral shoulder and hip girdle aching, 90-minute morning stiffness, ESR 92 mm/hr, and CRP 58 mg/L. There are no features of giant cell arteritis. What is the first-line treatment?
- Naproxen 500mg twice daily
- Hydroxychloroquine 400mg daily
- Prednisolone 15mg daily (Correct answer)
- Methotrexate 15mg weekly
Correct answer: Prednisolone 15mg daily
Polymyalgia rheumatica is treated with prednisolone 15mg daily initially, with gradual dose reduction guided by symptoms and inflammatory markers; NSAIDs alone are insufficient.
Question 2: A 32-year-old man develops asymmetric oligoarthritis, urethritis, and conjunctivitis 3 weeks after an episode of Campylobacter gastroenteritis. HLA-B27 is positive. What is the most likely diagnosis?
- Gonococcal arthritis
- Reactive arthritis (Correct answer)
- Ankylosing spondylitis
- Enteropathic arthritis
Correct answer: Reactive arthritis
Reactive arthritis is a seronegative spondyloarthropathy triggered by genitourinary or gastrointestinal infection, presenting with the classic triad of arthritis, urethritis, and conjunctivitis.
Question 3: A 48-year-old woman with long-standing Raynaud's phenomenon develops skin thickening confined to the hands and face, telangiectasia, and anti-centromere antibodies. Which long-term complication carries the greatest mortality risk in her condition?
- Scleroderma renal crisis
- Pulmonary arterial hypertension (Correct answer)
- Diffuse alveolar haemorrhage
- Rapidly progressive glomerulonephritis
Correct answer: Pulmonary arterial hypertension
Limited cutaneous systemic sclerosis with anti-centromere antibodies confers a high risk of pulmonary arterial hypertension, which is a leading cause of death in this subtype.
Question 4: Which antibody is most closely associated with diffuse cutaneous systemic sclerosis and predicts an increased risk of pulmonary fibrosis?
- Anti-centromere
- Anti-Scl-70 (anti-topoisomerase I) (Correct answer)
- Anti-Jo-1
- Anti-Mi-2
Correct answer: Anti-Scl-70 (anti-topoisomerase I)
Anti-Scl-70 (anti-topoisomerase I) antibodies are associated with diffuse cutaneous SSc and predict a substantially higher risk of interstitial lung disease.
Question 5: A 47-year-old woman presents with 3 months of proximal muscle weakness, CK 3,800 U/L, heliotrope discolouration of the eyelids, and Gottron's papules over the knuckles. Which investigation is most important to arrange urgently?
- Anti-dsDNA antibody titre
- CT thorax, abdomen and pelvis (Correct answer)
- Nerve conduction studies
- Tensilon test
Correct answer: CT thorax, abdomen and pelvis
Adult-onset dermatomyositis has a strong association with underlying malignancy; CT TAP is mandatory to screen for occult cancer at diagnosis.
Question 6: A 35-year-old woman with SLE has suffered three first-trimester miscarriages and one DVT. Lupus anticoagulant and anti-cardiolipin IgG are positive on two occasions 12 weeks apart. What is the most appropriate long-term antithrombotic treatment?
- Aspirin 75mg daily alone
- Warfarin with target INR 2–3 (Correct answer)
- Rivaroxaban 20mg daily
- Low molecular weight heparin indefinitely
Correct answer: Warfarin with target INR 2–3
Antiphospholipid syndrome with confirmed venous thrombosis requires long-term warfarin targeting an INR of 2–3; direct oral anticoagulants are not recommended in APS due to evidence of higher recurrence rates.
Question 7: A 68-year-old man presents with acute onset of a hot, erythematous, severely swollen right knee. Joint aspirate shows cloudy fluid with WBC 85,000/mm³ (92% neutrophils) and Gram-positive cocci in clusters on Gram stain. What is the most appropriate immediate management?
- Oral flucloxacillin and outpatient review in 48 hours
- IV flucloxacillin and urgent joint washout (Correct answer)
- Colchicine and naproxen
- Intra-articular corticosteroid injection
Correct answer: IV flucloxacillin and urgent joint washout
Septic arthritis (most likely Staphylococcus aureus) is a medical emergency requiring IV antibiotics and surgical joint washout to prevent irreversible cartilage destruction.
MRCP Part 1 Rheumatology 2
A 74-year-old woman presents with 6 weeks of bilateral shoulder and hip girdle aching, 90-minute morning stiffness, ESR 92 mm/hr, and CRP 58 mg/L.
There are no features of giant cell arteritis.
What is the first-line treatment?