Systemic Lupus Erythematosus and Connective Tissue Diseases — WACS Viva & Clinical Scenarios (Rheumatology and Clinical Immunology)

Exam-style systemic lupus erythematosus and connective tissue diseases viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: A 24-year-old female presents with persistent low-grade fever, polyarthritis of the small joints of the hands, facial rash, lower limb swelling, and dark-colored urine. Investigations reveal serum creatinine 182 micromol/L, proteinuria 3.8 g/24 hours, active urine sediment with red blood cell casts, positive antinuclear antibodies with a homogeneous pattern, elevated anti-dsDNA titers, and depressed serum C3 and C4 levels. Discuss the diagnostic workup, ISN/RPS histological classification of lupus nephritis, differentiation from tropical mimickers, and evidence-based induction and maintenance
• SCENARIO 2: A 38-year-old woman with a 3-year history of Raynaud phenomenon and progressive skin thickening of the fingers, forearms, and face presents to the emergency unit with severe headache, blurred vision, and dyspnea. Her blood pressure is 210/115 mmHg, serum creatinine has acutely risen from 75 to 260 micromol/L, and peripheral blood smear shows microangiopathic hemolytic anemia. Outline the pathophysiological mechanism, serological risk factors, immediate pharmacological management, and contraindications in scleroderma renal crisis, as well as the long-term surveillance protocols for pulmonary ar
• SCENARIO 3: A 29-year-old female with a history of two unprovoked deep vein thromboses and three consecutive first-trimester pregnancy losses presents for preconception counseling. Laboratory workup confirms high-titer IgG anticardiolipin antibodies, positive lupus anticoagulant, and positive anti-beta-2-glycoprotein I antibodies confirmed 14 weeks apart. Detail the diagnostic criteria for antiphospholipid syndrome, risk stratification of the antiphospholipid antibody profile, secondary antithrombotic prophylaxis, and the specific management protocol required throughout pregnancy and the postpartum period
• SCENARIO 4: A 46-year-old male presents with progressive proximal muscle weakness in the shoulder and pelvic girdles, dysphagia, violaceous periorbital edema, and erythematous scaly papules over the metacarpophalangeal and interphalangeal joints. Serum creatine kinase is markedly elevated at 4,200 IU/L. Discuss the diagnostic evaluation including myositis-specific autoantibodies, electromyography, and muscle biopsy features; malignancy screening requirements; and the multidisciplinary therapeutic approach to idiopathic inflammatory myopathies and antisynthetase syndrome.
• SCENARIO 5: A 32-year-old female presents with severe xerophthalmia, xerostomia, bilateral parotid gland enlargement, fatigue, and widespread arthralgia. Evaluation reveals positive anti-Ro/SSA and anti-La/SSB antibodies. Discuss the classification criteria for primary Sjogren syndrome, objective tests for glandular dysfunction, surveillance for hematological malignancies, and the clinical implications and management of positive anti-Ro/SSA antibodies in a prospective pregnancy regarding neonatal lupus erythematosus.