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Ferritin as Acute Phase Reactant — SCE Rheumatology MCQ

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ModerateAutoimmune SerologyFerritin as Acute Phase ReactantSCE Rheumatology

A 55-year-old woman with established rheumatoid arthritis has active synovitis. Her serum ferritin is 1850 microg/L, CRP 85 mg/L and ESR 72 mm/h. Transferrin saturation is 22%. Full blood count and liver biochemistry are normal. She has not received blood transfusions and reports no fever, evanescent rash or sore throat. What is the most likely explanation for the elevated ferritin?

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Correct answer: E — Inflammation-associated hyperferritinaemia from active rheumatoid arthritis

The best answer is E. Ferritin is both an iron-storage protein and a positive acute-phase reactant. Objectively active rheumatoid arthritis, normal transferrin saturation, normal liver biochemistry and no transfusion history make reactive inflammatory hyperferritinaemia most likely. HFE-related haemochromatosis and transfusional iron overload usually produce evidence of increased iron availability, particularly raised transferrin saturation, making B and E less likely. Normal liver biochemistry argues against acute hepatocellular injury. Ferritin elevation alone does not establish adult-onset Still disease; the characteristic systemic phenotype, including spiking fever and often an evanescent rash, is absent. A ferritin of 1850 microg/L remains substantial: if persistent or disproportionate, infection, liver disease, malignancy and macrophage activation syndrome should still be considered.

Reference: Gurumurthy G, Brown R, Thachil J. Investigation of a raised ferritin—hereditary haemochromatosis or not? QJM. 2026;119(4):257-264. https://pubmed.ncbi.nlm.nih.gov/41543274/