Early inflammatory arthritis — SCE Rheumatology MCQ

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ModerateRheumatoid arthritisEarly inflammatory arthritisSCE Rheumatology

A 34-year-old woman has an 8-week history of symmetrical metacarpophalangeal joint swelling and prolonged morning stiffness. Examination confirms synovitis of both wrists and several proximal interphalangeal joints. CRP is 28 mg/L, rheumatoid factor is negative, and plain radiographs of the hands and feet show no erosions. Which is the most appropriate next investigation?

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Correct answer: E — Anti-CCP antibody testing

Anti-CCP antibody testing is the most appropriate investigation. This patient has persistent symmetrical small-joint synovitis strongly suggestive of early rheumatoid arthritis, despite negative rheumatoid factor and normal radiographs. NICE recommends considering anti-CCP testing when suspected RA is rheumatoid-factor negative. A positive result supports the diagnosis and indicates an increased risk of radiographic progression. Normal radiographs do not exclude early RA, and investigations must not delay urgent specialist assessment. Serum urate is primarily relevant to suspected gout, while creatine kinase assesses muscle injury or inflammatory myopathy. HLA-B27 testing may help in selected axial or enthesitis-predominant spondyloarthritis presentations. Anti-centromere antibodies are associated principally with limited cutaneous systemic sclerosis.

Reference: National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management (NG100), section 1.1, Referral, diagnosis and investigations. 2018, updated 2020 and reviewed 2024. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations