MCQs in Rheumatology:
Inflammatory arthritis
Contributors: These MCQs were written by Dr Dipti Patel, Dr Frances Rees,
Dr Pravin Patil, Dr Kar-Ping Kuet, Dr Michelle Hui, and Dr Roshan
Amarasena; and were reviewed by Dr Philip Courtney, Prof Andy Hassell, and
Prof Nigel Arden, Dr Adrian Jones, and Dr Neal Hopkinson. The MCQs were
edited by
Dr A Abhishek who also facilitated the review process.
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Question 1
A 70 year old man with rheumatoid arthritis is in pre-op clinic prior to an
elective total knee replacement in 6 weeks’ time. His current medication
includes Methotrexate and Etanercept. The orthopaedic FY2 doctor contacts
you for advice.
You should advise the FY2 doctor to
1.
2.
3.
4.
5.
Continue both drugs
Stop Methotrexate and Etanercept 14 days before surgery
Stop Methotrexate and Etanercept on the day of surgery
Stop Etanercept 14 days before surgery, continue methotrexate
Stop Etanercept on the day of surgery, continue methotrexate
Question 2
A 30 year old lady with rheumatoid arthritis attends follow up appointment 8
weeks after the birth of her first child. She stopped hydroxychloroquine 8
weeks ago, concerned about using it whilst breast feeding. She intends to
breast feed for four more months. She has a swollen right knee. There is no
history of trauma. 50 ml viscous, straw colored synovial fluid was drained, and
the knee was injected with 80 mg methylprednisolone.
Which of the following statements is the best management for her arthritis?
1. Avoid hydroxychloroquine while breast feeding
2. Avoid hydroxychloroquine when breast feeding, and start oral
corticosteroids
3. Restart hydroxychloroquine
4. Give oral NSAIDs
5. Start methotrexate
Question 3
A 45-year old woman presents with a 2 month history of joint pains and early
morning stiffness. She does not smoke and takes alcohol in moderation. On
examination, you find swelling and tenderness of both wrists, and of the index
and middle finger metacarpo-phalangeal joints bilaterally.
Investigations:
Hb 11.5 g/dL (low), MCV 80 fL, WCC 6.2 x109/L, urea 7 mmol/L, creatinine 92
µmol/L,
ALT 25 iu/L, ANA negative, ANCA negative, rheumatoid
factor positive. Chest x-ray is normal.
Which of the following is the most appropriate initial management plan for this
patient?
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1.
2.
3.
4.
5.
Corticosteroids
Methotrexate and sulphasalazine
Methotrexate, sulphasalazine and hydroxychloroquine
Methotrexate, hydroxychloroquine and corticosteroids
Methotrexate and corticosteroids
Question 4
A 55 year old male smoker with active rheumatoid arthritis for 6 years, who
has failed combination therapy with methotrexate 25 mg weekly, sulfasalazine
1 gm BD, and hydroxychloroquine 200mg BD, was commenced on
Etanercept six months ago. While on etanercept (50 mg/week) and
methotrexate (7.5mg/week), he developed ST elevation anterior myocardial
infarction. He had thrombolytic therapy, and appropriate secondary preventive
measures. Since discharge, he is feeling well, but gets short of breath on
walking uphill. General physical examination reveals bilateral pedal oedema
(mild), and is otherwise unremarkable. A FBC, UEC, urine dipstick, and LFT
are normal.
Which of the following tests would you do next to decide whether to stop
etanercept treatment?
1.
2.
3.
4.
5.
Coronary angiogram
ECG
Echocardiogram
Stress echocardiogram
Thallium scan
Question 5
A 24 year old child minder with rheumatoid arthritis for three years is on
Methotrexate 20 mg weekly, and Leflunomide 10 mg OD. She was
commenced on 15 mg prednisolone OD 2 weeks ago for flare of RA. One of
the children she is looking after has developed chicken pox. She has not had
chicken pox in the past, and blood tests prior to starting methotrexate showed
that she did not have IgG antibodies to varicella.
Which of the following is the correct approach for her in this situation?
1.
2.
3.
4.
5.
She should stop her DMARDs if she develops chickenpox
She should stop her DMARDs for 3 weeks
She should have chicken pox vaccination
She should be administered varicella zoster immunoglobulin
She should stop her steroids, and continue on DMARDs
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Question 6
A 36 year old female with a 5 year history of rheumatoid arthritis on
methotrexate 15mg/week attends for annual review. Her DAS 28 score is
1.95, and she has not had any articular symptoms in the last 12 months. She
must travel to mid-Africa for some important business, and has been advised
to take yellow fever vaccine for this. She is quite keen to take the vaccine, and
asks you what to do about the methotrexate.
How many months before the vaccination should she discontinue the
methotrexate?
1. 2 weeks
2. 1 month
3. 2 months
4. 3 months
5. 6 months
Question 7
A 67 year old male presents to the Rheumatology department with a 5 week
history of pain and swelling of the wrists and dorsum of the hands. He has
pronounced early morning stiffness. On examination he has – swelling,
warmth, tenderness of MCPJs, PIPJs, and wrists. He has pitting oedema of
dorsum of both hands, and feet. Lab investigations reveal a CRP-82 mg/l,
ESR-100 mm/hr. He is ANA, rheumatoid factor, and anti-CCP negative. Urine
dipstick is unremarkable.
X ray hands showed narrowing of joint spaces in 5th proximal and distal
Interphalangeal joints, no erosive changes.
Which of the following is the best initial treatment option for him?
1.
2.
3.
4.
5.
Non steroidal anti inflammatory drugs
Methotrexate (7.5-15mg/week)
Methotrextae (7.5-15mg/week) plus oral prednisolone 15 mg OD
Prednisolone 60 mg OD with rapid tapering
Prednisolone 15 mg OD tapered slowly
Question 8
A 22 year old fit and well man presents to his GP with a 2 day history of left
ankle pain and swelling. He has no history of trauma and is generally well in
himself. He had diarrhoea for 2 days while on holiday in Egypt 3 weeks ago.
On examination T - 37.2oC, HR-86/min regular, BP -126/82 mm Hg. General
and systemic examination was unremarkable. Musculoskeletal examination
reveals a tender, swollen left ankle.
Which of the following microbe is least likely to trigger reactive arthritis?
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1.
2.
3.
4.
5.
Chlamydia trachomatis
Klebsiella pneumonia
Salmonella species
Shigella species
Yersinia enterocolitica
Question 9
A 25 year old woman presents to the medical admissions unit with a 2 week
history of swollen ankles, and a rash on her legs. On examination she has
bilateral ankle effusions and erythematous tender nodules on her shins.
Which investigation is most useful to aid your diagnosis?
1.
2.
3.
4.
5.
Borrelia serology
C reactive protein
Chest radiograph
Rheumatoid factor
Serum ACE level
Question 10
A 63 year old woman with rheumatoid arthritis is seen for review after
commencing leflunomide 20mg od, 6 weeks ago. She previously discontinued
Methotrexate and Sulfasalazine due to side effects. For the past 10 days she
had noticed an increasingly itchy rash appearing over her trunk and limbs. On
examination she had discrete blanching erythematous papules over her
abdomen and limbs.
What is the most appropriate next step in management?
1.
2.
3.
4.
5.
Stop leflunomide
Stop leflunomide, prescribe cholestyramine 8mg tds
Stop leflunomide, prescribe cholestyramine 8g tds
Stop leflunomide, prescribe cetirizine 10mg od
Stop leflunomide, prescribe prednisolone 10mg od
Question 11
A 30 year old man returned from a six week holiday in Thailand. He presented
with dysuria, conjunctivitis and painful swollen joints. His general practitioner
performed the following blood tests
Rheumatoid factor- Negative
ANA- Negative
CRP 35 mg/L
ESR 60 mm/hr
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In view of the likely diagnosis, which of the following features will you
specifically look for?
1.
2.
3.
4.
5.
Circinate balanitis
Calcinosis
Dermographism
Heliotrope rash
Pathergy
Question 12
A thirty-sixty year old man presents with seronegative inflammatory arthritis
(anti-CCP, and rheumatoid factor negative) predominantly affecting the knees,
and the DIPJs. There is no past or family history of psoriasis.
Which of the following is true about psoriatic arthritis?
1. Site of psoriasis involvement increases the risk of psoriatic arthritis
2. Nail pitting, and onycholysis do not associate with arthritis
3. Over 60% psoriasis patients develop inflammatory arthritis
4. Psoriatic arthritis may precede skin involvement in 15-30% cases
5. Severity of skin involvement increases the risk of psoriatic arthritis
Question 13
A 36 year old man is seen in A& E with a swollen right ankle for three weeks.
He denies any trauma. He has bloody diarrhoea with abdominal pain for past
two months. On examination he has right ankle synovitis, is able to weight
bear, and move the joint with little difficulty. Sigmoidoscopic biopsy confirms a
diagnosis of ulcerative colitis.
Which one of the following is incorrect regarding ulcerative colitis associated
arthropathy?
1.
2.
3.
4.
5.
Anti-saccharomyces cerevisiae mannan antibodies are commonly negative
Erythema nodosum may be present
Inflammatory arthropathy is the most common extra intestinal manifestation
pANCA is positive in 60% patients with ulcerative colitis
pANCA titres correlate with joint disease
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Answers
Q1.
4. Stop Etanercept 10 days before surgery, continue
methotrexate
Although the BSR guidelines suggest that the decision to treat with anti-TNF
agents in the peri-operative period should be balanced between the risk of
infection, and disease flare, most clinicians would be comfortable with
suggesting that anti-TNF agents be withdrawn 3-5 half lives before the
operative procedure.
Q2.
3. Restart hydroxychloroquine
Hydroxychloroquine is safe in both pregnancy and breastfeeding. Flare of RA
commonly occurs within first 3 months post-partum. The knee swelling is most
probably the inflammatory disease which has flared post partum. There is no
need to start oral steroids yet. Methotrexate is not safe in pregnancy or
breastfeeding and must be stopped at least 3 months before trying to
conceive.
Q3.
2.Methotrexate, hydroxychloroquine and corticosteroids
Steroids are quick acting and are appropriate initial management for RA.
However, other disease-modifying agents take longer to have an effect. NICE
guidelines (CG79 February 2009) recommends combination DMARDs plus
short course corticosteroid. Hence amongst the options available, oral
glucocorticoids, methotrexate and hydroxychloroquine is the most appropriate
choice.
Q4.
3. Echocardiogram
Exertional shortness of breath can be a presenting symptom of heart failure.
Patients with CCF who are on anti-TNF agents have a worse outcome.
According to the BSR guidelines, anti-TNF therapy should not be initiated in
patients with New York Heart Association (NYHA) Grade 3 or 4 cardiac
failure, and should be used with caution in patients with mild (NYHA Grade 1
or 2) cardiac failure. Anti-TNF therapy should be discontinued if CF develops
or worsens while on treatment. As ejection fraction can be assessed from a
simple 2D echocardiogram, this is the initial investigation of choice.
Q5.
4. She should be administered varicella zoster immunoglobulin
Immunosuppressed patients without a history of chickenpox/ or herpes zoster
should receive varicella –zoster immunoglobulin (VZIG) if they have exposure
to a case of chickenpox/ or zoster. Depending on local policy, patients may be
checked for anti-herpes zoster antibodies (to establish that they have not had
a sub-clinical infection) before starting VZIG. You should consult your duty
virologist/microbiologist for advice about these patients.
An exposure to varicella zoster virus is significant if
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i. The index case has chickenpox, disseminated shingles or an exposed
localised lesion e.g. ophthalmic zoster. If the index case is
immunosuppressed then a local lesion anywhere may be significant as
shedding is greater in these.
ii. Exposure occurs between 48 hours before onset of rash to crusting of all
lesions (chickenpox) or from day of onset of rash to crusting of all lesions in
shingles.
iii. Contact with index case is in the same room e.g. in a house or classroom
or 2-6 bed hospital bay for at least 15 minutes or direct face to face contact
e.g. while having a conversation for more than about 5 minutes.
Q6.
4. 3 months
BSR guidelines suggest that in patients on immunosuppressives like
azathioprine, methotrexate, leflunomide, cyclophosphamide, cyclosporin, and
biologics, the use of live vaccines is contra-indicated unless
immunosuppressive are stopped at least 3 months beforehand. If use of live
vaccines is necessary allow at least 2 weeks, preferably 4 weeks, before
immunosuppressive therapy is commenced. If a patient is vaccinated while
taking immunosuppressive they may not mount the appropriate immune
response. Consider repeating 3 months after therapy has ceased if viral titres
low.
Only 2 live attenuated viruses, yellow fever and polio, are used regularly for
foreign travel.
• Yellow fever - this must not be given. Patients should be advised not to
travel to countries requiring this e.g. mid-Africa. If the patient has to travel, an
exemption statement may be accepted but the patient will be at risk.
• Polio vaccine - the live oral vaccine must not be given. Killed inactivated
vaccine can be given but may need to be obtained from abroad so adequate
notice must be given.
• Typhoid - the live form should not be given. Killed vaccine is available but
only 70%protective.
• Inactive viruses can be given e.g. Rabies, Anthrax, Cholera, Plague.
Q7.
5. Prednisolone 15 mg OD tapered slowly
Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a
benign arthritis which can achieve remission with low dose corticosteroids.
The condition is characterized by symmetrical synovitis in peripheral joints
and pitting edema on the dorsum of the hands, primarily affecting the elderly.
Patients with RS3PE syndrome can be classified as following onset at age ≥
65 years, negative RF and ANA tests, symmetrical synovitis involving wrists,
metacarpophalangeal, interphalangeal, tarsal, metatarsophalangeal joints,
tenosynovitis of the flexor and extensor joints of the hands, pitting edema of
the involved joints, morning stiffness, rapid response to low dose
corticosteroid treatment, and exclusion of other pathologies .There can be
systemic signs like fever and weakness in RS3PE syndrome but radiographic
joint destruction is not observed. Patients are not treated with DMARDs,
unless symptoms recur on tapering corticosteroids.
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Q8.
2. Klebsiella pneumonia
Reactive arthritis is an autoimmune condition that develops in response to an
infection. It usually develops 2-4 weeks after a genitourinary or
gastrointestinal infection. Reactive arthritis has been associated with
gastrointestinal infections with Shigella, Salmonella, Campylobacter, Yersinia
species and other microorganisms, as well as with genitourinary infections
(especially with Chlamydia trachomatis).Recent evidence indicates that
preceding respiratory infection with Chlamydia pneumoniae may also trigger
the disease. About 10% of patients do not have any preceding infection.
The onset of reactive arthritis is usually acute and characterized by malaise,
fatigue, and fever. An asymmetrical, predominately lower-extremity,
oligoarthritis is the major presenting symptom. Low-back pain occurs in 50%
of patients. Heel pain is common because of enthesopathies at the Achilles or
plantar aponeurosis insertion on the calcaneus.
Q9.
3.Chest radiograph
This young woman is presenting with symptoms of Sarcoidosis (synovitis and
erythema nodosum). Although Serum ACE would usually be checked, 40%
patients have a normal level at the time of diagnosis. A chest radiograph
would be more useful to look for evidence of bilateral hilar lymphadenopathy.
This is present in 90% of patients and would make the triad of Lofgren’s
syndrome.
Q10.
3.Stop leflunomide and prescribe cholestyramine 8g tds
This is a drug reaction to leflunomide. Due to the long half life, leflunomide
requires a washout with cholestyramine. The dose is 8g tds for 11 days.
Q11.
1. Circinate balanitis
A triad of urethritis, conjunctivitis and seronegative arthritis affecting large
joints may occur in reactive arthritis. Other features are anterior uveitis,
keratoderma blenorrhagica (skin lesions commonly found on the palms and
soles but which may spread to the penis- circinate balanitis, scalp and trunk),
mouth ulcers, plantar fasciitis and enthesopathy. Non-gonococcal urethritis
usually not seen in the absence of sexual intercourse.
Q12.
cases
4. Psoriatic arthritis may precede skin involvement in 15-30%
There is no association between the site, or severity of psoriasis and
arthropathy. Approximately 15-30% patients with psoriasis develop psoriatic
arthritis.
Q13. 5. pANCA titres correlate with joint disease
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Ulcerative colitis (UC) predominantly affects the colon and rectum. Arthritis is
the commonest extra intestinal feature. Other extra-intestinal features are
erythema nodosum, pyoderma gangrenosum, episcleritis, iritis, sclerosing
cholangitis and thrombosis. pANCA is positive in 60% and does not correlate
with disease activity. Anti-saccharomyces cerevisiae mannan antibodies are
negative in ulcerative colitis.
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