Rheumatology (SLE, RA, Vasculitis, Crystal Arthropathies, Scleroderma) MCQs

Medicine · 193 free questions with answers & explanations.

1. A 28-year-old woman presents with arthralgia, malar rash, oral ulcers, and pleuritis. Labs: ANA 1:640 (homogeneous), anti-dsDNA positive, C3 low, C4 low, proteinuria 3.5 g/day. Renal biopsy shows mesangial and subendothelial deposits with wire-loop lesions. Which WHO/ISN class of lupus nephritis does this represent?
2. A 55-year-old woman with long-standing seropositive rheumatoid arthritis presents with Raynaud phenomenon, dysphagia, skin tightening over the hands, and telangiectasias. Anti-centromere antibody is positive. This antibody is most strongly associated with:
3. A 65-year-old man with a history of hypertension presents with acute, severe monoarthritis of the first metatarsophalangeal joint (podagra), fever, and joint aspiration showing negatively birefringent, needle-shaped crystals under polarized light. Which metabolic abnormality most commonly underlies this condition?
4. A 68-year-old woman presents with bilateral aching of the shoulders, neck, and hips for 3 months with morning stiffness lasting over 45 minutes. ESR is 88 mm/hr, CRP elevated, and rheumatoid factor is negative. There is no synovitis or weakness. The most appropriate initial treatment is:
5. A 34-year-old woman with known SLE presents with a serum creatinine that has risen from 0.8 to 2.4 mg/dL over 3 months. Urinalysis shows RBC casts, 3+ proteinuria. Anti-dsDNA antibodies are 480 IU/mL (very high), complement C3 is 48 mg/dL (low). Renal biopsy shows endocapillary and mesangial proliferation with subendothelial immune deposits and wire-loop lesions. What is the WHO/ISN class of this lupus nephritis?
6. A 60-year-old man with long-standing tophaceous gout and serum urate of 9.8 mg/dL is started on allopurinol 100 mg daily. Three weeks later he develops a generalized erythematous macular rash, fever (39.1°C), eosinophilia, and lymphadenopathy. Liver enzymes are elevated 5-fold. What is the most likely diagnosis?
7. A 48-year-old woman with diffuse cutaneous systemic sclerosis presents with progressive dyspnea on exertion. Echocardiography shows an estimated right ventricular systolic pressure of 58 mmHg. Pulmonary function tests show a markedly reduced DLCO (42% predicted) with preserved FVC. The most likely underlying mechanism of her pulmonary hypertension in this context is:
8. A 55-year-old woman with rheumatoid arthritis on methotrexate and hydroxychloroquine presents with bilateral lower limb weakness, loss of sensation below T6, and bladder dysfunction developing over 2 days. MRI spine shows cervical cord compression at C3–C4. Neurological examination reveals hyperreflexia. What is the most likely structural cause of her myelopathy?
9. A 40-year-old man presents with recurrent oral ulcers (>3 episodes/year), genital ulcers, a hypopyon in the left eye, and erythema nodosum-like skin lesions. The pathergy test is positive. What is the most likely diagnosis?
10. A 28-year-old woman with SLE on hydroxychloroquine has persistently active nephritis (24-hour urine protein 3.2 g, cellular casts). Renal biopsy shows diffuse proliferative nephritis (class IV). Which combination is now recommended as first-line induction therapy per the ACR 2019/EULAR 2019 guidelines?
11. A 55-year-old man presents with episodic severe pain in the first MTP joint. Serum urate is 9.8 mg/dL. He has two gout flares in the past 6 months. His GFR is 45 mL/min. Which urate-lowering therapy is most appropriate as first-line?
12. A 45-year-old woman with diffuse cutaneous systemic sclerosis develops progressive dyspnoea. High-resolution CT chest shows basilar honeycombing and ground-glass opacities. PFTs show restrictive pattern. Anti-topoisomerase-I (anti-Scl-70) antibody is positive. Which treatment has shown the best evidence for slowing SSc-ILD progression in clinical trials?
13. A 62-year-old woman develops sudden-onset painless visual loss in the left eye. She has a 6-month history of scalp tenderness, jaw claudication, and morning stiffness. ESR is 95 mm/hr, CRP is markedly elevated. What is the most important immediate next step?
14. A patient with established RA on methotrexate (MTX) for 6 months has persistent moderate disease activity (DAS28 = 4.2). Per ACR guidelines, what is the next most appropriate step?
15. A 45-year-old woman with RA on methotrexate develops progressive dyspnoea and a honeycombing pattern on HRCT. Pulmonary function shows restrictive pattern with reduced DLCO. Her RA is well controlled. What is the most likely pulmonary complication?
16. Anti-MDA5 (anti-melanoma differentiation-associated gene 5) antibody is associated with which specific clinical phenotype in inflammatory myopathies?
17. In the pathogenesis of gout, uric acid crystals activate the NLRP3 inflammasome in macrophages, leading to release of which key pro-inflammatory cytokine responsible for acute gout attacks?
18. The 2022 ACR/EULAR classification criteria for ANCA-associated vasculitis distinguish GPA (granulomatosis with polyangiitis) from MPA (microscopic polyangiitis) primarily using which antibody:
19. A woman with diffuse cutaneous systemic sclerosis develops worsening hypertension (BP 190/110), microangiopathic haemolytic anaemia, and creatinine rising to 3.2 mg/dL over days. What is the cornerstone treatment that transformed prognosis of this complication?
20. A 28-year-old woman with SLE develops worsening renal function, haematuria with red cell casts, proteinuria 3.8 g/day, and complement consumption. Renal biopsy shows diffuse proliferative glomerulonephritis (ISN/RPS Class IV). The MOST appropriate induction immunosuppressive regimen per current EULAR/ACR guidelines is:
21. A 55-year-old man with longstanding seropositive RA develops symmetrical peripheral neuropathy, weight loss, skin nodules, and mononeuritis multiplex. ANA is negative; ANCA (p-ANCA, anti-MPO) is positive at high titre. The MOST likely diagnosis is:
22. A 62-year-old man presents with acute monoarthritis of the first MTP joint. Joint fluid shows negatively birefringent needle-shaped crystals under polarised light microscopy. Serum uric acid is 5.8 mg/dL (normal). The CORRECT interpretation is:
23. Anti-centromere antibodies (ACA) in systemic sclerosis are MOST specifically associated with which subset and its visceral complication?
24. A 48-year-old man with known GPA (granulomatosis with polyangiitis, formerly Wegener's) is in remission on azathioprine. He develops worsening haematuria and is found to have anti-PR3 ANCA titre rising from 1:40 to 1:320. Creatinine is stable at 1.1 mg/dL. The MOST appropriate next action is:
25. A 32-year-old woman with SLE presents with nephrotic range proteinuria (4.5 g/day), hematuria, and hypertension. Renal biopsy shows diffuse endocapillary proliferation, wire-loop lesions, and subendothelial immune deposits (IgG, IgM, C3, C1q — full house). The ISN/RPS classification of this nephritis is:
26. A 55-year-old woman with a 10-year history of RA on methotrexate and etanercept develops dry eyes, dry mouth, parotid enlargement, and positive anti-Ro and anti-La antibodies. Which additional autoantibody, if strongly positive, would raise concern for lymphoma development?
27. A 48-year-old man with a 20-year history of tophaceous gout presents with acute monoarthritis. His serum urate is 9.2 mg/dL. He has stage 3b CKD (eGFR 35) and is on hydrochlorothiazide for hypertension. The urate-lowering drug of choice in this patient with CKD, based on CARES and FAST trials evidence, is:
28. A 42-year-old woman presents with Raynaud's phenomenon, puffy fingers, telangiectasias, and mild esophageal dysmotility. ANA is positive; anti-centromere antibody is strongly positive. Anti-Scl-70 (anti-topoisomerase I) is negative. The most likely clinical course and complication to monitor for is:
29. A 62-year-old man with long-standing RA on methotrexate and leflunomide presents with subacute onset of bilateral lower lobe crackles, reduced exercise tolerance, and high-resolution CT showing ground-glass opacities with honeycombing in basal segments. Pulmonary function tests show FVC 65% predicted, DLCO 55%. The MOST likely diagnosis and the AAC-based pattern is:
30. A 30-year-old woman with SLE presents with worsening dyspnea and a loud P2. Echo shows pulmonary artery systolic pressure of 62 mmHg. ANA, anti-dsDNA, and anti-U1-RNP antibodies are positive. What is the pathophysiologic mechanism of pulmonary hypertension in this setting?
31. In the 2010 ACR/EULAR classification criteria for Rheumatoid Arthritis, a patient scores ≥6 points and is classified as definite RA. The scoring domains include joint involvement, serology, duration, and acute-phase reactants. Which serology finding gives the HIGHEST score (3 points)?
32. A 55-year-old woman with limited cutaneous systemic sclerosis (lcSSc) develops worsening exertional dyspnea. She has anti-centromere antibodies, calcinosis, Raynaud's, and telangiectasia (CREST). Echo suggests elevated RVSP. What is the most common cause of death in lcSSc?
33. A 65-year-old man with tophaceous gout has serum urate of 9.8 mg/dL despite allopurinol 300 mg/day. His eGFR is 52 mL/min. He reports multiple gout flares per year. Which management step is most appropriate?
34. ANCA-associated vasculitis is classified based on ANCA specificity and clinical pattern. Which vasculitis is most strongly associated with anti-myeloperoxidase (MPO-ANCA / p-ANCA)?
35. A 35-year-old woman with SLE develops rising creatinine, proteinuria 2.4 g/day, and red cell casts. Renal biopsy shows diffuse proliferative nephritis. According to current EULAR/ERA-EDTA guidelines, what is the preferred induction regimen?
36. A 28-year-old woman with known antiphospholipid syndrome had a cerebral venous sinus thrombosis 6 months ago. She is currently on warfarin with INR 2.5. She is now being considered for elective surgery. Which anticoagulation strategy is most appropriate for her perioperative bridging?
37. A 52-year-old man with long-standing gout and visible tophi on both elbows has serum urate of 9.4 mg/dL despite allopurinol 300 mg/day. He has eGFR of 55 mL/min and is intolerant of febuxostat. Which agent is specifically approved for refractory gout with inadequate response to xanthine oxidase inhibitors?
38. A 45-year-old woman with limited systemic sclerosis develops progressive exertional dyspnoea. Echocardiogram shows PASP 52 mmHg. Right heart catheterization confirms mean PAP 32 mmHg, PCWP 10 mmHg, PVR 5 Wood units. According to current ESC/ERS guidelines, what is her WHO functional classification and recommended first-line therapy?
39. A 32-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria (2.8 g/day), hematuria, and a rising creatinine (1.8 mg/dL). Renal biopsy shows diffuse proliferative glomerulonephritis with full-house immunofluorescence. According to EULAR/ACR 2024 guidelines, the preferred induction therapy in this patient is:
40. A 58-year-old man with established RA on methotrexate 20 mg/week has inadequate response (DAS28 score 5.4) after 6 months. He has no prior infections or heart failure. According to ACR 2021 guidelines, the preferred next therapeutic addition is:
41. A 68-year-old man presents with sudden severe right toe pain, swelling, and redness. Serum uric acid is 9.2 mg/dL. He is on hydrochlorothiazide for hypertension. Synovial fluid shows negatively birefringent, needle-shaped crystals. During the acute attack, the MOST appropriate anti-inflammatory agent given his normal renal function is:
42. A 45-year-old woman presents with Raynaud's phenomenon, dysphagia, telangiectasias, and tight skin limited to the hands and face. She is anti-centromere antibody positive. Which complication requires urgent cardiac monitoring and is the leading cause of death in this subset?
43. A 55-year-old man with known eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss) has recurrent sinus disease, asthma, peripheral eosinophilia >1500 cells/μL, and positive p-ANCA (anti-MPO). He develops wrist drop. The first-line biological therapy approved for relapsing or refractory EGPA is:
44. A 30-year-old woman with SLE presents with serum creatinine rising from 0.8 to 2.1 mg/dL over 4 weeks. Urinalysis shows RBC casts and 3+ proteinuria. Renal biopsy reveals diffuse endocapillary proliferation with 'wire loop' lesions and subendothelial immune deposits by electron microscopy. This represents which ISN/RPS lupus nephritis class?
45. A 55-year-old man with a 10-year history of RA on methotrexate 20 mg/week develops progressive dyspnea. HRCT chest shows bilateral basilar reticulation with honeycombing and traction bronchiectasis. Pulmonary function tests show FVC 58% predicted, DLCO 45% predicted. The most likely diagnosis is:
46. A 48-year-old man presents with recurrent attacks of exquisitely painful right first MTP joint swelling. Serum uric acid is 9.8 mg/dL. Joint aspirate shows negatively birefringent needle-shaped crystals. He has a creatinine of 1.9 mg/dL (eGFR 38 mL/min). Which urate-lowering therapy is most appropriate?
47. A 40-year-old woman with limited cutaneous systemic sclerosis (lcSSc) develops exertional dyspnea. Echo shows estimated RVSP of 52 mmHg and right heart catheterization confirms mPAP 32 mmHg, PCWP 12 mmHg, PVR 4.2 Wood units. The most important initial investigation to guide prognosis in this SSc-PAH patient is:
48. A 62-year-old woman presents with bilateral temporal headache, jaw claudication, and a tender, non-pulsatile right temporal artery. ESR is 98 mm/hr, CRP 45 mg/L. The IMMEDIATE next step is:
49. A 30-year-old woman with known SLE on hydroxychloroquine presents with worsening proteinuria (2.8 g/day), haematuria, and hypertension. Renal biopsy shows mesangial and subendothelial immune deposits with 'wire-loop' lesions. What class of lupus nephritis does this represent and what is the initial treatment?
50. A 45-year-old woman with RA on methotrexate and etanercept develops a 2-week productive cough, night sweats, and a 4 kg weight loss. Chest X-ray shows right upper lobe infiltrate with cavitation. What is the most critical first step before continuing biological therapy?
51. A 62-year-old man presents with acute monoarthritis of the right knee. Joint fluid aspiration shows negatively birefringent needle-shaped crystals on polarised light microscopy. Serum uric acid is 5.8 mg/dL (normal). Which statement is most accurate?
52. A 52-year-old woman with systemic sclerosis (diffuse cutaneous SSc) presents with new onset dyspnoea and progressive exertional limitation over 3 months. HRCT shows basal-predominant fine reticulation with ground-glass opacity. Spirometry: FVC 62% predicted, DLCO 48% predicted. What is the current evidence-based first-line treatment for SSc-ILD?
53. A 38-year-old woman presents with recurrent oral and genital ulcers, uveitis, and pathergy. She is from Turkey. The most characteristic vascular complication of her likely diagnosis is:
54. A 35-year-old woman with SLE has serum complement C3 22 mg/dL (low), anti-dsDNA titre rising from 1:80 to 1:640, and new-onset haematuria with RBC casts on urinalysis. Creatinine has risen from 0.9 to 1.8 mg/dL over 6 weeks. The MOST likely class of lupus nephritis and RECOMMENDED induction therapy is:
55. In granulomatosis with polyangiitis (GPA, formerly Wegener's), the ANCA pattern on indirect immunofluorescence and the target antigen are:
56. A 58-year-old man with a history of hypertension and diuretic use presents with acute monoarthritis of the first MTP joint. Synovial fluid shows needle-shaped, negatively birefringent crystals. Serum urate is 9.8 mg/dL. He has had 4 attacks in the past year. After controlling the acute attack, the MOST appropriate long-term urate-lowering target is:
57. Anti-topoisomerase I (anti-Scl-70) antibodies are most strongly associated with which subset of systemic sclerosis and its primary complication?
58. The 2022 ACR/EULAR criteria for rheumatoid arthritis require a score ≥ 6 for classification. A patient has 8 small joints involved (swollen/tender), positive high-titre anti-CCP, CRP 2× normal, and symptom duration of 7 weeks. What is the MINIMUM total score achieved in this scenario?
59. A 28-year-old woman with SLE develops Class III lupus nephritis confirmed on renal biopsy. Per current EULAR/ACR 2019 guidelines, what is the preferred induction immunosuppression regimen?
60. Anti-Jo-1 antibodies are associated with which specific constellation of findings in inflammatory myopathy?
61. A 55-year-old man has 3 weeks of fever, weight loss, sinusitis, haemoptysis, and haematuria. c-ANCA/PR3-ANCA is positive. Renal biopsy shows pauci-immune crescentic glomerulonephritis. Per current EULAR guidelines, which induction regimen is preferred for severe ANCA-associated vasculitis?
62. Tophaceous gout results from chronic monosodium urate crystal deposition. Which serum urate target is recommended per ACR 2020 guidelines to dissolve tophi and prevent recurrent gout attacks?
63. A patient with scleroderma (systemic sclerosis) develops acute-onset oliguria, hypertensive emergency (BP 220/140 mmHg), and microangiopathic haemolytic anaemia. Creatinine rises from 0.9 to 3.8 mg/dL over 3 days. What is the most important specific treatment for scleroderma renal crisis?
64. A 32-year-old woman with known SLE on hydroxychloroquine develops a serum creatinine rise from 0.8 to 2.4 mg/dL over 4 weeks. Urine shows red cell casts and 3+ proteinuria. Renal biopsy shows diffuse proliferative changes with wire-loop lesions on light microscopy and granular 'full house' immunofluorescence (IgG, IgM, IgA, C3, C1q). This is CLASS:
65. A 55-year-old woman with seropositive RA on methotrexate (MTX) 20 mg/week and sulfasalazine has persistent active disease (DAS28 >3.2). Which is the MOST evidence-based next step per ACR/EULAR treat-to-target guidelines?
66. A 48-year-old man presents with acute monoarthritis of the first MTP joint (podagra). Serum uric acid is 9.8 mg/dL. Joint aspiration demonstrates negatively birefringent needle-shaped crystals. He is started on urate-lowering therapy. Per current ACR gout guidelines, what is the serum uric acid TARGET for patients with tophi?
67. A 40-year-old woman with diffuse cutaneous systemic sclerosis develops a sudden rise in blood pressure (220/120 mmHg) and acute kidney injury (creatinine 4.5 mg/dL) with microangiopathic hemolytic anemia. This complication is called scleroderma renal crisis. The FIRST-LINE treatment is:
68. A 35-year-old woman with SLE has a positive lupus anticoagulant and anti-cardiolipin IgG >40 GPL units on two occasions 12 weeks apart, without any thrombotic event. Which is the MOST appropriate thromboprophylaxis strategy?
69. A 62-year-old man presents with rapidly progressive glomerulonephritis, hemoptysis, and sinusitis. cANCA/PR3-ANCA is strongly positive. Renal biopsy shows pauci-immune crescentic glomerulonephritis. This is granulomatosis with polyangiitis (GPA). Induction therapy consists of:
70. A 35-year-old woman with SLE has worsening proteinuria (3.2 g/day), hematuria, and creatinine of 1.8 mg/dL. Renal biopsy shows mesangial and subendothelial deposits with wire-loop lesions on light microscopy and global subendothelial deposits on electron microscopy. What is the WHO/ISN-RPS class of lupus nephritis?
71. A 50-year-old man with long-standing RA develops cervical myelopathy. MRI shows atlantoaxial subluxation with anterior atlantodental interval of 6 mm. What is the most important reason to assess this before any elective surgery under general anesthesia?
72. A 65-year-old woman presents with rapidly progressive glomerulonephritis, hemoptysis, and pANCA (MPO-ANCA) positivity. Renal biopsy shows pauci-immune crescentic glomerulonephritis. Which regimen is currently recommended as induction therapy?
73. A 55-year-old man with gout has a serum urate of 9.8 mg/dL and has had three attacks in the past year. He has a history of allopurinol hypersensitivity syndrome. Which urate-lowering therapy is most appropriate?
74. A 42-year-old woman with diffuse cutaneous systemic sclerosis develops acute onset dyspnea, pulmonary crackles, and an oxygen saturation of 88%. CT chest shows ground-glass opacities and reticular pattern predominantly in lower lobes. Pulmonary function tests show FVC 52%, DLCO 44%. What is the first-line treatment for this pulmonary complication?
75. A 32-year-old woman with SLE on hydroxychloroquine has worsening lupus nephritis class III confirmed on biopsy. Her creatinine has risen from 0.8 to 1.4 mg/dL. Per EULAR/ERA-EDTA 2019 guidelines, what is the recommended induction regimen?
76. A 58-year-old man with long-standing RA develops progressive shortness of breath. HRCT shows bilateral basal predominant reticulation with honeycombing and traction bronchiectasis. PFTs reveal a restrictive pattern with reduced DLCO. The most likely pulmonary complication of RA is:
77. A 65-year-old woman with known GPA (granulomatosis with polyangiitis) develops severe alveolar hemorrhage with diffuse pulmonary infiltrates and haemoptysis, along with creatinine rising to 3.8 mg/dL and ANCA (PR3) strongly positive. Which treatment is currently preferred as adjunct to standard induction (rituximab or cyclophosphamide + steroids) for life-threatening disease?
78. A 45-year-old woman with diffuse cutaneous systemic sclerosis (dcSSc) develops acute hypertensive crisis with BP 190/110 mmHg, headache and rising creatinine. Urinalysis shows proteinuria and microscopic haematuria. This complication is best managed with:
79. A 50-year-old man presents with acute monoarthritis of the first MTP joint, erythema and extreme tenderness. Serum uric acid is 9.8 mg/dL. Joint aspiration shows negatively birefringent needle-shaped crystals. He has CKD stage 3 (eGFR 42). Which urate-lowering therapy is first-line with dose adjustment in CKD?
80. Anti-Jo-1 antibody is characteristically associated with which clinical syndrome in inflammatory myopathy?
81. A 32-year-old woman with SLE presents with worsening proteinuria (4.5 g/day), hypertension, and serum creatinine rising to 2.1 mg/dL over 3 months. Renal biopsy shows diffuse proliferative lupus nephritis (ISN/RPS Class IV). What is the current recommended induction immunosuppression per ACR 2021 guidelines?
82. A 55-year-old woman with long-standing seropositive RA on methotrexate for 3 years has progressive joint erosions and DAS28-CRP of 5.8 (high disease activity). She is started on a biologic. She is a non-smoker with no prior TB, no hepatitis B, and a normal chest X-ray. Which biologic is FIRST-LINE as add-on to methotrexate per ACR/EULAR guidelines?
83. A 48-year-old man presents with recurrent acute monoarthritis of the first MTP joint. Synovial fluid analysis reveals negatively birefringent needle-shaped crystals under polarized light microscopy. His serum uric acid is 9.2 mg/dL and he has urate deposits visible on ultrasound. He has had 3 flares in the past year. Per current ACR 2020 gout guidelines, at what serum uric acid target should urate-lowering therapy be maintained?
84. A 45-year-old woman with systemic sclerosis (diffuse cutaneous SSc) develops acute onset hypertension (220/130 mmHg), rising creatinine, microangiopathic hemolytic anemia, and thrombocytopenia. Which treatment is most critical to preserve renal function?
85. A 65-year-old woman presents with new-onset temporal headache, scalp tenderness, jaw claudication, and ESR of 95 mm/hr. Vision is normal at presentation. Which is the MOST important immediate management step?
86. A 38-year-old woman with SLE has a positive lupus anticoagulant, anti-cardiolipin IgG antibodies (>40 GPL units), and anti-beta-2-glycoprotein-I antibodies on two occasions 12 weeks apart. She has no prior thrombosis. What is this serological profile called and what prophylactic treatment is recommended?
87. A 30-year-old woman with SLE presents with pleuritic chest pain and shortness of breath. Chest X-ray shows bilateral small pleural effusions. Echocardiography reveals a pericardial effusion. Anti-dsDNA titre is markedly elevated and complement C3/C4 are low. Her current regimen is hydroxychloroquine. The most appropriate addition to her treatment is:
88. A 55-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week and hydroxychloroquine continues to have active disease (DAS28-CRP 4.2). Anti-CCP antibodies are positive; RF is positive. Per EULAR guidelines, the most appropriate next step in disease management is:
89. A 68-year-old man presents with sudden severe pain in his left knee. Synovial fluid analysis shows positively birefringent rhomboid crystals under polarised light microscopy. His serum calcium is 2.8 mmol/L. The most likely underlying cause to investigate is:
90. A 45-year-old woman presents with Raynaud's phenomenon, dysphagia for solids, salt-and-pepper skin changes, calcinosis, and telangiectasias. ANA is positive with anti-centromere antibody pattern. The most likely diagnosis and its most serious pulmonary complication are:
91. A 60-year-old man presents with fever, weight loss, sinusitis, haemoptysis, and haematuria. ANCA testing shows c-ANCA (anti-PR3) positivity. Renal biopsy shows focal segmental necrotising glomerulonephritis with crescents and paucity of immune deposits. The induction therapy with the strongest evidence (RAVE and RITUXVAS trials) is:
92. A 32-year-old woman with SLE on hydroxychloroquine and prednisolone presents with worsening proteinuria (3.5 g/day) and an active urinary sediment with RBC casts. Renal biopsy shows diffuse proliferative nephritis with subendothelial and mesangial immune deposits. Which ISN/RPS class is this?
93. A 55-year-old woman with longstanding seropositive RA on methotrexate 20 mg weekly is started on a biologic. Three months later she develops sudden onset fever, dry cough, progressive dyspnoea, and hypoxia. High-resolution CT shows bilateral ground-glass opacities. Bronchoscopy lavage shows lymphocytosis. What is the MOST likely cause?
94. A 64-year-old man presents with a 3-month history of fatigue, 6 kg weight loss, new onset headache, scalp tenderness, and jaw claudication. ESR is 88 mm/h. Fundoscopy is normal. Which investigation is now recommended FIRST before initiating treatment, according to ACR/EULAR 2021 guidelines?
95. A 48-year-old woman presents with episodic pallor followed by cyanosis then erythema of all fingers on cold exposure, oral mucosal telangiectasias, heartburn, and skin tightening of the fingers extending to the elbows. Anti-centromere antibodies are positive. Which complication is she MOST at risk for?
96. A 52-year-old man with obesity and hypertension presents with acute monoarthritis of the first MTP joint. Serum urate is 9.8 mg/dL. During this acute episode, which of the following is the correct management regarding urate-lowering therapy (ULT)?
97. A 32-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria (3.2 g/day), haematuria, and serum creatinine rises to 2.1 mg/dL over 3 weeks. Renal biopsy shows diffuse endocapillary proliferative glomerulonephritis with subendothelial immune deposits. What is the initial induction regimen of choice?
98. A 55-year-old man with longstanding seropositive RA develops bilateral hand deformity and now presents with neck pain and sudden onset of gait ataxia. X-ray of the cervical spine (lateral in flexion) shows an atlanto-dens interval of 7 mm. What complication is most likely?
99. A 44-year-old man presents with recurrent oral ulcers, genital ulcers, uveitis, and pathergy test positivity. Which HLA type is most strongly associated with this condition?
100. A 60-year-old woman presents with progressive dysphagia, Raynaud's phenomenon, sclerodactyly, and telangiectasias. ANA is positive with an anticentromere antibody pattern. What is the pulmonary complication she is most at risk for?
101. A 68-year-old man with gout on allopurinol 300 mg/day presents with a serum urate of 7.8 mg/dL. He has stage 3a CKD (eGFR 52 mL/min). Target serum urate for a patient with recurrent tophaceous gout is less than 5 mg/dL per current guidelines. What is the most appropriate next step?
102. A 70-year-old woman presents with proximal muscle weakness, elevated CK (8× ULN), heliotrope rash, Gottron's papules, and mechanic's hands. Anti-MDA5 antibody is negative. Anti-Mi-2 antibody is positive. What is the expected pulmonary pattern?
103. A 34-year-old woman with SLE and a history of two first-trimester miscarriages tests positive for lupus anticoagulant and anticardiolipin IgG on two occasions 12 weeks apart. She is now 8 weeks pregnant. According to current EULAR guidelines, the recommended prophylactic regimen is:
104. A 48-year-old man with a 15-year history of severe gout on allopurinol 300 mg/day has a serum urate of 8.4 mg/dL. He has no renal impairment. He cannot tolerate febuxostat due to cardiovascular concerns. According to ACR 2020 guidelines, what is the recommended next step?
105. A 52-year-old woman with limited systemic sclerosis (lcSSc) develops progressive exertional dyspnoea. Right heart catheterisation shows mean PAP 32 mmHg, PVR 4.2 Wood units, PCWP 10 mmHg. The most likely diagnosis and first-line treatment are:
106. Which serological marker is most specific for diffuse cutaneous systemic sclerosis (dcSSc) with highest risk of renal crisis?
107. A 41-year-old woman with RA maintained on methotrexate 20 mg/week develops rising DAS28 score (4.8) despite adequate MTX dosage for 6 months. She has no contraindications to biologics. According to ACR 2021 guidelines, which add-on treatment is recommended as first-line biologic?
108. A 35-year-old woman with SLE (anti-dsDNA positive, low complement) presents with serum creatinine 2.4 mg/dL and 3+ proteinuria. Renal biopsy shows diffuse proliferative glomerulonephritis. According to EULAR/ERA-EDTA 2019 guidelines, what is the recommended induction immunosuppression?
109. Which finding on immunofluorescence of a skin biopsy of non-lesional sun-exposed skin is most specific for systemic lupus erythematosus?
110. A 55-year-old woman with long-standing diffuse cutaneous systemic sclerosis develops exertional dyspnoea. Right heart catheterisation reveals mean pulmonary arterial pressure 35 mmHg and pulmonary capillary wedge pressure 12 mmHg. Which antibody is most characteristically associated with pulmonary arterial hypertension in systemic sclerosis?
111. A 68-year-old man presents with acute onset of severe pain, warmth, and swelling of the right knee. Joint aspiration shows weakly positive birefringent crystals under polarised light microscopy. X-ray of the knee shows chondrocalcinosis. What is the most likely diagnosis and causative crystal?
112. In the ORCHESTRA trial framework, the treat-to-target (T2T) strategy in rheumatoid arthritis aims to achieve which primary target by 6 months if remission is not achieved?
113. A 32-year-old woman with SLE has serum creatinine 2.1 mg/dL, proteinuria 3.8 g/day, and urine RBC casts. Renal biopsy shows WHO class IV lupus nephritis. Which treatment regimen is now preferred as induction therapy per 2019 EULAR recommendations for class IV lupus nephritis?
114. A 48-year-old woman presents with dry eyes, dry mouth, parotid enlargement, arthralgia, and purpura on the lower limbs. Anti-Ro/SSA and anti-La/SSB antibodies are positive. Her serum protein electrophoresis shows polyclonal hypergammaglobulinemia. Rheumatoid factor is positive at 1:640. Which complication is most concerning in this patient?
115. A 65-year-old man with rheumatoid arthritis has been on methotrexate 20 mg/week for 3 years with good disease control but now has DAS28 of 4.2. Anti-CCP is strongly positive. Per EULAR 2022 guidelines, which is the recommended next step?
116. A 40-year-old man presents with saddle nose deformity, sinusitis, haemoptysis, haematuria, and serum creatinine 2.8 mg/dL rising over 3 weeks. c-ANCA (PR3-ANCA) is strongly positive. What is the most appropriate induction therapy?
117. A 55-year-old man with tophaceous gout has serum urate of 9.8 mg/dL on allopurinol 300 mg/day and is intolerant of higher doses due to skin rash. Which agent is most appropriate to lower urate to target (<5 mg/dL)?
118. A 34-year-old woman with SLE has been on hydroxychloroquine for 2 years. She now presents with proteinuria 2.8 g/day, haematuria, and creatinine 1.6 mg/dL. Renal biopsy shows diffuse proliferative glomerulonephritis (Class IV). What is the preferred induction therapy according to current ACR guidelines?
119. A 48-year-old man with long-standing gout and multiple tophi has serum urate of 9.8 mg/dL despite allopurinol 600 mg/day. He has normal renal function (eGFR 72). What is the most appropriate next step?
120. A 62-year-old woman with seropositive erosive RA has failed two conventional DMARDs. Anti-CCP antibodies are strongly positive. She has no tuberculosis risk factors, eGFR 65, and no hepatitis B. Which biologic or targeted synthetic DMARD has cardiovascular safety data that should be considered in a patient with a history of MI 3 years ago?
121. A 55-year-old woman with systemic sclerosis (diffuse cutaneous) develops acute onset dyspnoea, dry cough, and ground-glass opacities on HRCT. Spirometry shows FVC 64% predicted, DLCO 52%. Anti-topoisomerase I (anti-Scl-70) antibodies are positive. What is the current first-line treatment for SSc-ILD?
122. Which ANCA pattern and target antigen is most characteristically associated with granulomatosis with polyangiitis (GPA, formerly Wegener's)?
123. A 35-year-old woman with SLE develops progressive dyspnea, pleuritic chest pain, and hemoptysis. CT pulmonary angiogram shows no PE. BAL shows hemosiderin-laden macrophages. The most likely diagnosis is:
124. A 28-year-old woman with SLE has a serum creatinine of 1.8 mg/dL, proteinuria 3.2 g/day, and active urinary sediment (RBC casts). Renal biopsy shows diffuse mesangial and subendothelial immune deposits with wire-loop lesions. ISN/RPS classification of lupus nephritis in this case is:
125. A 52-year-old woman with long-standing rheumatoid arthritis is found to have neutropenia (ANC 0.9 × 10⁹/L) and splenomegaly. She has no fever. Which condition should be suspected?
126. A 42-year-old woman with limited systemic sclerosis (CREST syndrome) develops progressive exertional dyspnea. Right heart catheterization shows mean pulmonary arterial pressure 32 mmHg, pulmonary capillary wedge pressure 10 mmHg, pulmonary vascular resistance 4.2 WU. What is the diagnosis and what autoantibody is classically associated?
127. A 55-year-old man with gout has a serum urate of 9.8 mg/dL and two flares in the past year. He is started on allopurinol. The target serum urate level per ACR 2020 gout management guidelines is:
128. Which of the following best describes the mechanism of action of belimumab in the treatment of SLE?
129. A 28-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria (3.8 g/day), haematuria, and rising creatinine. Renal biopsy shows diffuse proliferative glomerulonephritis with 'wire-loop' lesions and subendothelial immune deposits. What is the current first-line induction therapy?
130. A 52-year-old woman with long-standing seropositive RA inadequately controlled on methotrexate 20 mg/week develops Felty's syndrome. Which haematological finding is characteristic of Felty's syndrome?
131. A 65-year-old man presents with a 3-week history of bitemporal headache, jaw claudication, and ESR 92 mm/hr. Temporal artery biopsy is being arranged. What is the most appropriate immediate action?
132. A 44-year-old woman with limited cutaneous systemic sclerosis (lcSSc) presents with worsening dyspnoea. HRCT shows ground-glass opacities and fine reticulation in both lower lobes. PFTs reveal FVC 64% predicted. What is the current evidence-based first-line disease-modifying treatment for SSc-ILD?
133. A 58-year-old man presents with acute monoarthritis of the first metatarsophalangeal joint, serum urate 9.2 mg/dL, and a prior episode 8 months ago. He is on hydrochlorothiazide for hypertension. After managing the acute attack, which drug is preferred for urate-lowering therapy given his reduced eGFR of 48 mL/min?
134. A 28-year-old woman with SLE on hydroxychloroquine has new-onset nephrotic-range proteinuria (4.8 g/day), haematuria, and creatinine 1.9 mg/dL. Anti-dsDNA titre is high and C3/C4 are low. Renal biopsy shows diffuse proliferative changes with 'wire-loop' deposits on light microscopy. Which ISN/RPS class is this and what is the first-line treatment?
135. A 55-year-old man with longstanding RA on methotrexate + adalimumab develops a 3 cm non-tender nodule at the extensor surface of the left elbow, lymphadenopathy, and B symptoms (fever, night sweats, weight loss). Biopsy of an enlarged lymph node shows large B-cell lymphoma. What is the most likely explanation?
136. A 62-year-old man presents with a swollen, hot right first metatarsophalangeal joint. Synovial fluid shows negatively birefringent needle-shaped crystals under polarised light microscopy. Serum uric acid is 5.8 mg/dL (normal). Which statement is most accurate about this scenario?
137. Which pulmonary complication is most commonly the cause of death in limited cutaneous systemic sclerosis (lcSSc)?
138. Granulomatosis with polyangiitis (GPA) most characteristically involves which combination of findings, and what is the associated ANCA pattern?
139. A 35-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria of 3.8 g/day. Renal biopsy shows mesangial hypercellularity, subendothelial deposits, and wire-loop lesions with full-house immunofluorescence (IgG, IgM, IgA, C3, C1q). The ISN/RPS class and MOST appropriate first-line induction therapy are:
140. A 55-year-old man with long-standing RA on methotrexate and adalimumab develops persistent dry cough, progressive dyspnoea, and bilateral basal crackles. HRCT chest shows bilateral lower lobe reticulation with honeycombing and traction bronchiectasis. The MOST likely pulmonary complication of RA is:
141. A 68-year-old man has an acute monoarthritis of the right knee with turbid synovial fluid. Polarised light microscopy shows positively birefringent rhomboid crystals. Which of the following statements about this condition is CORRECT?
142. A 48-year-old woman has diffuse cutaneous systemic sclerosis (dcSSc) complicated by scleroderma renal crisis. Her BP is 195/110 mmHg and serum creatinine has risen from 0.9 to 3.2 mg/dL over 5 days. Anti-RNA polymerase III antibodies are positive. The treatment of CHOICE is:
143. In ANCA-associated vasculitis (granulomatosis with polyangiitis), which ANCA pattern and target antigen combination is MOST specific for the diagnosis?
144. A 34-year-old woman with known SLE presents with new haematuria, proteinuria 3.5 g/day, and serum creatinine 180 µmol/L. Renal biopsy shows diffuse glomerulonephritis with 'full house' immunofluorescence (IgG, IgM, IgA, C3, C1q). The ISN/RPS 2018 classification for this pattern is:
145. A 45-year-old man with known gout has a serum uric acid of 620 µmol/L despite allopurinol 300 mg/day. He is intolerant to higher doses of allopurinol (creatinine 155 µmol/L, eGFR 48). The MOST appropriate next urate-lowering option is:
146. Which of the following correctly describes the pathophysiology of PR3-ANCA (c-ANCA) in granulomatosis with polyangiitis (GPA)?
147. A 52-year-old woman with diffuse cutaneous systemic sclerosis (dcSSc) develops acute hypertensive crisis (BP 220/130 mmHg) with microangiopathic haemolytic anaemia, thrombocytopenia, and rising creatinine. This is scleroderma renal crisis. The MOST important immediate treatment is:
148. Calcium pyrophosphate deposition (CPPD) disease is associated with several metabolic conditions. Which metabolic disorder should be PRIMARILY screened when a 50-year-old man presents with acute CPPD arthritis of the knee?
149. A 40-year-old woman with diffuse cutaneous systemic sclerosis develops progressive exertional dyspnea, RHC shows mPAP 42 mmHg, PVR 5.2 Wood units, PCWP 10 mmHg, confirming Group 1 PAH. Her FVC is 72% predicted with DLCO 42%. Per EULAR and ACR guidelines, which treatment is most appropriate?
150. A 55-year-old man with rheumatoid arthritis on methotrexate + adalimumab develops fever, cough, and bilateral ground-glass opacities on CT chest. BAL shows no pathogens. Serum beta-D-glucan is negative. The patient improved briefly after stopping adalimumab and starting broad-spectrum antibiotics, but worsened again. What is the most likely diagnosis?
151. A 30-year-old woman with SLE presents with painless gross hematuria, RBC casts, rising creatinine (1.8 mg/dL from baseline 0.9), and 24-hour protein of 2.9 g. Renal biopsy shows diffuse endocapillary and mesangial proliferation with 'wire-loop' lesions and subendothelial immune deposits on EM. Anti-dsDNA is 1:640 and C3/C4 are low. Per EULAR 2023 recommendations, what is the induction regimen?
152. A 65-year-old man presents with large joint mono/oligoarthritis, calcium pyrophosphate crystals (weakly positive birefringent rhomboid crystals) in synovial fluid, chondrocalcinosis on knee X-ray, and mild hypomagnesemia. Which underlying condition should be screened for?
153. A 55-year-old man with GPA (granulomatosis with polyangiitis) previously in remission on rituximab maintenance develops rising ANCA titer (PR3-ANCA ×4 rise), but no clinical symptoms or organ damage. What is the recommended management per EULAR vasculitis guidelines?
154. A 32-year-old woman with SLE presents with new-onset hypertension, rising creatinine, thrombocytopenia, and microangiopathic haemolytic anaemia. Anti-dsDNA titres are elevated and complement is low. Which diagnosis BEST explains this picture?
155. A 58-year-old woman with RA on methotrexate and adalimumab develops a new dry cough, dyspnoea, and bilateral ground-glass opacities on HRCT. BAL is negative for infection. The MOST likely diagnosis and the APPROPRIATE management change is:
156. Regarding the Chapel Hill Consensus Classification of vasculitides, ANCA-associated vasculitis (AAV) includes which three conditions?
157. A 42-year-old man with longstanding tophaceous gout has a serum urate of 9.8 mg/dL despite maximum-tolerated allopurinol. He has stage 3a CKD. The BEST addition to lower serum urate to target (<5 mg/dL for tophaceous gout) is:
158. Diffuse cutaneous systemic sclerosis (dcSSc) is associated with which antibody most predictive of scleroderma renal crisis?
159. A patient with SLE develops worsening proteinuria. Renal biopsy shows diffuse proliferative glomerulonephritis (Class IV per ISN/RPS classification). Per current ACR guidelines, the induction immunosuppressive regimen of choice is:
160. In giant cell arteritis (GCA), the TREAT GCA trial evaluated which biologic that is now approved for GCA to reduce relapse and cumulative glucocorticoid dose?
161. In systemic sclerosis (SSc), which autoantibody is MOST strongly associated with scleroderma renal crisis (SRC) and mandates urgent ACE inhibitor use?
162. A 55-year-old man with gout has serum urate of 9.8 mg/dL and has had 3 attacks in the past year. He also has CKD stage 3. What is the serum urate TARGET recommended during urate-lowering therapy according to current guidelines?
163. A 42-year-old woman with systemic sclerosis (diffuse cutaneous form) has a serum creatinine that has doubled over 5 days. Blood pressure is 175/108 mmHg. Urinalysis shows mild proteinuria. Peripheral smear shows schistocytes. What is the most appropriate immediate therapy?
164. In ANCA-associated vasculitis (granulomatosis with polyangiitis), which combination regimen is recommended for remission induction in organ-threatening or life-threatening disease according to EULAR/ERA 2022 guidelines?
165. A patient with gout has a serum uric acid of 9.8 mg/dL, two attacks in the past year, and one visible tophus on the left elbow. When should urate-lowering therapy (ULT) be initiated, and what serum uric acid target should be achieved?
166. In antiphospholipid syndrome (APS), which antibody combination confers the highest thrombotic risk (triple positivity)?
167. A 38-year-old woman with SLE on hydroxychloroquine develops new heavy proteinuria 3.8 g/day, serum creatinine 1.9 mg/dL, and low complement. Renal biopsy shows mesangial and subendothelial deposits with wire-loop lesions and fibrinoid necrosis. Based on ISN/RPS 2003 and 2018 classifications, what class of lupus nephritis is this?
168. A 62-year-old woman with seropositive rheumatoid arthritis on methotrexate 20 mg/week has DAS28-CRP of 4.9 after 6 months. Anti-CCP titre is > 3× ULN and she has erosions on X-ray. Per EULAR 2022 and ACR 2021 guidelines, the most appropriate next step is:
169. A 58-year-old man with a history of kidney transplant presents with severe foot pain and swelling in the first metatarsophalangeal joint. He is on tacrolimus and mycophenolate. Synovial fluid shows negatively birefringent needle-shaped crystals. Serum uric acid is 10.2 mg/dL. Which urate-lowering therapy is most appropriate given his immunosuppressive regimen?
170. A patient with diffuse cutaneous systemic sclerosis (dcSSc) has Rodnan skin score 30, FVC 62% predicted, DLCO 41%, and HRCT showing extensive honeycombing and traction bronchiectasis. Which treatment has the strongest evidence for slowing progression of SSc-ILD?
171. A 45-year-old woman presents with right orbital pain worsening on eye movement, scalp tenderness, and jaw claudication. ESR is 98 mm/h and CRP 66 mg/L. Temporal artery biopsy is being planned. What histological finding is diagnostic of giant cell arteritis (GCA)?
172. A 35-year-old woman with diffuse cutaneous systemic sclerosis develops acute kidney injury with blood pressure 180/110 mmHg. Urinalysis shows mild proteinuria and granular casts. What is the BEST initial treatment for scleroderma renal crisis?
173. Which antibody in SLE is MOST strongly associated with secondary anti-phospholipid syndrome (APS) and recurrent arterial thrombosis?
174. A 62-year-old woman on long-term methotrexate for RA develops new pulmonary infiltrates and eosinophilia. Which condition is the MOST likely cause?
175. A 68-year-old man with a long history of poorly controlled gout develops 'tophaceous' deposits. Serum urate is 9.2 mg/dL on maximum dose allopurinol. He has stage 3 CKD. What is the MOST appropriate treatment escalation?
176. A 55-year-old man with granulomatosis with polyangiitis (GPA) achieves remission with cyclophosphamide and prednisolone. For maintenance of remission, current EULAR guidelines recommend:
177. A 38-year-old woman with established SLE (on hydroxychloroquine) develops worsening arthritis, new oral ulcers, thrombocytopenia (platelets 68,000/µL), and serositis. Complement C3 and C4 are both low, and anti-dsDNA titre has risen 4-fold. The SELENA-SLEDAI score has increased by 8 points. Which scoring instrument would specifically classify this as a 'severe flare'?
178. A 55-year-old woman with limited cutaneous systemic sclerosis (lcSSc) on nifedipine for Raynaud's develops progressive dyspnoea. HRCT chest shows bibasilar ground-glass opacities and fine reticulation. PFTs show FVC 68%, DLCO 58%. Bronchoalveolar lavage shows 8% neutrophils and 5% eosinophils. Anti-topoisomerase I (anti-Scl-70) antibody is positive. What is the most appropriate initial disease-modifying therapy?
179. A 68-year-old man presents with severe acute monoarthritis of the first MTP joint. Serum uric acid is 9.8 mg/dL. He has a history of stage 3 CKD and is currently on aspirin 81 mg/day for CAD. Which urate-lowering therapy (ULT) is PREFERRED as first-line in this patient?
180. A 45-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week and hydroxychloroquine continues to have active disease (DAS28-CRP = 4.8). Anti-CCP antibodies are strongly positive and RF is positive. What is the preferred next step per 2022 ACR RA guidelines?
181. Calcium pyrophosphate deposition disease (CPPD) causing pseudogout most commonly deposits crystals in which intra-articular structure, and what is the characteristic appearance on plain radiograph?
182. A 28-year-old woman with SLE develops progressive shortness of breath over 6 weeks. CT pulmonary angiography is negative for PE. HRCT shows bilateral lower lobe ground-glass opacities. BAL shows haemosiderin-laden macrophages. Complement levels are low. The MOST likely diagnosis is:
183. A 50-year-old man with known gout presents with a serum urate of 9.8 mg/dL despite allopurinol 300 mg/day. Renal function is normal. He has frequent flares. What is the MOST appropriate next step in urate-lowering therapy?
184. Anti-RNA polymerase III antibody is most specifically associated with which scleroderma complication?
185. A 42-year-old woman with RA on methotrexate 20 mg/week and hydroxychloroquine develops worsening synovitis and DAS28-CRP of 4.8. Which biologic should be AVOIDED if she has a history of prior lymphoma 8 years ago (now in remission)?
186. Which vasculitis is characterised by granulomatous inflammation of the aorta and its major branches, predominantly affects women under 50 years, and shows skip lesions on histology?
187. A 32-year-old woman with SLE presents with serositis, active urine sediment, and proteinuria 3.2 g/day. Anti-dsDNA is markedly elevated and complement C3/C4 are low. Renal biopsy shows diffuse proliferative nephritis. Which induction regimen is MOST appropriate per current EULAR/ACR guidelines?
188. A 55-year-old man with long-standing tophaceous gout has serum urate of 10.8 mg/dL despite maximum tolerated allopurinol (600 mg/day). He has normal renal function and no contraindications. What is the NEXT appropriate step in urate-lowering therapy?
189. A 48-year-old woman with RA develops worsening peripheral neuropathy, purpuric skin lesions on the lower extremities, and mononeuritis multiplex. ANCA is negative. Which complication of RA is MOST likely?
190. Which autoantibody in systemic sclerosis (scleroderma) is MOST strongly associated with pulmonary arterial hypertension (PAH) without significant ILD?
191. A 62-year-old man presents with jaw claudication, scalp tenderness, and sudden visual loss in the right eye. ESR is 98 mm/hr. Which pathological finding in the temporal artery biopsy is MOST characteristic?
192. A 48-year-old man presents with hemoptysis, hematuria, and rapidly progressive glomerulonephritis (creatinine rising from 1.0 to 4.2 mg/dL in 2 weeks). CXR shows bilateral pulmonary infiltrates. Urinalysis shows RBC casts. cANCA (anti-PR3) is positive at high titer. Renal biopsy shows pauci-immune crescentic glomerulonephritis. Induction therapy is:
193. A 52-year-old woman presents with 3 months of proximal muscle weakness (inability to rise from a chair), dysphagia, and Gottron's papules on her knuckles. Serum CK is 4800 U/L. Anti-MDA5 antibody is positive. CXR shows bilateral ground-glass opacities. The most feared complication of anti-MDA5-positive dermatomyositis is: