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Gout on azathioprine — SCE Rheumatology MCQ

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HardCrystal arthropathiesGout on azathioprineSCE Rheumatology

A patient with diffuse cutaneous systemic sclerosis who recently received prednisolone 20 mg daily presents with BP 196/118 mmHg, acute kidney injury, thrombocytopenia and microangiopathic haemolysis. What is the priority disease-specific treatment?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Start and rapidly titrate an ACE inhibitor; do not stop solely for an early creatinine rise

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · C = shown as D

E is correct. This is scleroderma renal crisis: abrupt severe hypertension, renal failure and thrombotic microangiopathy in diffuse disease, with recent glucocorticoid exposure as a recognised risk. Prompt ACE inhibition is the cornerstone and should be rapidly titrated; creatinine may initially worsen and is not by itself a reason to stop. A adds a precipitating exposure and dangerously delays blood-pressure control. B omits the treatment associated with survival benefit. C and D assume thrombocytopenia establishes TTP, although renal-crisis microangiopathy commonly mimics it; ADAMTS13 can clarify a genuine competing diagnosis without postponing ACE inhibition. Dialysis may be required, but renal recovery can occur late, so ACE inhibition is usually maintained.

Reference: 2024 BSR guideline for management of systemic sclerosis: https://pmc.ncbi.nlm.nih.gov/articles/PMC11534099/