A 22-year-old man with osteosarcoma receives high-dose methotrexate 12 g/m² with hydration, urine alkalinization, and leucovorin rescue. At 48 hours his methotrexate level is 12 µmol/L (expected below 1 µmol/L), and SCr has risen from 0.8 to 2.4 mg/dL. Which action is most appropriate?

Give glucarpidase and continue leucovorin

Start hemodialysis and stop leucovorin

Continue hydration only and recheck in 48 hours

Hold leucovorin until SCr returns to baseline

A 65-year-old male with gout has frequent attacks despite allopurinol 300 mg daily. His serum uric acid level is 9.0 mg/dL and his creatinine clearance is 60 mL/min. Which is the most appropriate next step?

Increase allopurinol to 400 mg daily

Add probenecid 500 mg twice daily

Switch to pegloticase infusions

Switch to febuxostat 40 mg daily

A 7-year-old boy receiving induction chemotherapy for acute lymphoblastic leukemia has a temperature of 38.6°C. He is hemodynamically stable. Labs: WBC 1,800 cells/mm³ with 10% segmented neutrophils and 5% bands. What is his ANC, and which action is most appropriate?

ANC 270; start empiric IV cefepime promptly

ANC 1,800; observe without antibiotics

ANC 180; start oral amoxicillin/clavulanate at home

ANC 270; start filgrastim and withhold antibiotics

A 63-year-old woman with metastatic colorectal cancer is starting bolus fluorouracil with leucovorin (Mayo regimen) on days 1–5 every 4 weeks. She has no oral lesions. Which measure is most appropriate to prevent oral mucositis?

Ice chips (oral cryotherapy) during each bolus

Chlorhexidine mouth rinse twice daily

Palifermin IV before each cycle

Fluconazole 100 mg orally daily throughout each cycle

A 64-year-old man with metastatic melanoma receives pembrolizumab every 3 weeks. Before cycle 5 he reports 5 more stools per day than his baseline, with mild cramping but no blood, fever, or dehydration. C. difficile and stool cultures are negative. Which action is most appropriate?

Hold pembrolizumab and start prednisone 1 mg/kg/day

Stop pembrolizumab permanently and start infliximab

Hold pembrolizumab and give supportive care only

Continue pembrolizumab and add loperamide

A 24-year-old woman with systemic lupus erythematosus has biopsy-proven class IV lupus nephritis: proteinuria 3.2 g/day, SCr 1.2 mg/dL, active sediment. She takes hydroxychloroquine and wants to preserve fertility; she uses an IUD. Which induction regimen is most appropriate?

Mycophenolate mofetil plus glucocorticoids

High-dose monthly IV cyclophosphamide plus glucocorticoids

Azathioprine plus glucocorticoids

A 58-year-old man with diffuse large B-cell lymphoma had a complete response to six cycles of R-CHOP, but biopsy confirms relapse 7 months after completing therapy. ECOG performance status is 0, and organ function is normal. Which treatment is most appropriate?

Axicabtagene ciloleucel (CAR T-cell therapy)

Polatuzumab vedotin, bendamustine and rituximab

Salvage R-ICE, then autologous transplant

A 61-year-old woman received axicabtagene ciloleucel 3 days ago. She now has temperature 39.6°C and BP 86/52 mm Hg that rose to 104/66 mm Hg after a 1-L fluid bolus, with SpO2 95% on room air (grade 2 cytokine release syndrome). Her neurologic examination and ICE score (10/10) are normal. Acetaminophen has been given. Which treatment is most appropriate?

Methylprednisolone 1 g IV daily

A 30-year-old woman had a complete hydatidiform mole evacuated 8 weeks ago. Her hCG has plateaued and then risen over 3 weeks, and low-risk gestational trophoblastic neoplasia (FIGO score 3, no metastases) is diagnosed. She has CKD from lupus nephritis with CrCl 38 mL/min. She wants to preserve fertility. Which treatment is most appropriate?

Actinomycin D single-agent therapy

Cisplatin-based combination therapy

Methotrexate with leucovorin rescue

EMA-CO combination chemotherapy

An 8-year-old boy (28 kg) with severe atopic dermatitis and moderate persistent asthma (on fluticasone) is starting dupilumab 300 mg SC every 4 weeks. His immunizations are up to date except the second MMR dose, which is due. Which counseling point is most appropriate?

Report eye redness, itching or discharge promptly

Give the second MMR dose during dupilumab therapy

Stop the inhaled fluticasone once dupilumab starts

Have CBC and liver tests checked every month

A 78-year-old man is newly diagnosed with AML (no FLT3, IDH1 or IDH2 mutation). His ECOG performance status is 2, and he has HFrEF with LVEF 35% and CrCl 48 mL/min. He wants treatment aimed at remission but is not a candidate for intensive chemotherapy. Which regimen is most appropriate?

Liposomal daunorubicin-cytarabine

Cytarabine plus daunorubicin (7+3)

A 72-year-old man with metastatic castration-resistant prostate cancer is on leuprolide (testosterone below 50 ng/dL) and declines chemotherapy. He has a history of epilepsy with a seizure 6 months ago. BP is 128/78 mm Hg, K 4.3 mEq/L, and liver enzymes are normal. He has not received any androgen-pathway agent. Which treatment is most appropriate to add?

Stop leuprolide and start enzalutamide

BCPS Oncology and Immunology: Supportive Care, Rheum

1Febrile neutropenia: do the arithmetic yourself

Treat febrile neutropenia as the oncology emergency to know cold. Practice calculating the absolute neutrophil count (ANC) until it takes seconds; a fever case in a patient on chemotherapy cannot be solved without it.

Then look past the ANC. Age, the current medication list and the rest of the history can each limit the choice, and a correct ANC paired with the wrong next step is still a wrong answer.

2The other emergencies, in one line each

Tumor lysis syndrome (TLS): Rapid cell breakdown releases potassium, phosphate and uric acid; calcium falls as phosphate binds it. The kidneys are both the casualty and the way out, so hydration and renal function drive most decisions.
Cytokine release syndrome (CRS): A systemic inflammatory reaction after T-cell-engaging therapy such as CAR T cells. Cases grade it by fever, blood pressure and oxygen need, and grade decides the step.
Immune effector cell neurotoxicity: A separate syndrome that can follow CRS or occur alone. Keep the two apart; their first-line treatments differ.
Immune-related adverse events: Checkpoint inhibitors can inflame almost any organ. Expect a grade and a decision about the checkpoint inhibitor itself.
Delayed drug clearance: Some high-dose agents depend on the kidneys to leave the body; a rising creatinine changes the plan within hours.

3Rheumatology, gout and allergy: the patient picks the drug

In rheumatology the useful question is seldom which disease-modifying drug works best. It is which one this patient’s other diagnoses allow: a drug class that suits most patients can be the wrong choice for one, so read the problem list first.

Gout and lupus cases sit here too, along with drug allergy and inflammatory syndromes in children. In each, the deciding fact is often a lab line or a sentence about the patient’s plans.

Before any biologic or targeted synthetic drug starts, screening and vaccine timing come into play. That workup is filed under Domain 2 and is covered in the therapeutics and patient management guide, where implementation and monitoring live.

4Where this material sits in the outline

BPS area labels; topic scope in our own words.
BPS area	What we cover here	Lighter touch
1C1 Oncology and Hematology	Supportive care, oncologic emergencies, immunotherapy and CAR T toxicity, anemias	First-line regimen selection by tumor stage
1C6 Allergy, Immunology and Rheumatology	RA, psoriatic arthritis, lupus, gout, inflammatory syndromes in children, drug allergy	Rare vasculitides
Transplant	Not named in the BCPS outline	Immunosuppressant levels and counseling can still appear under Domain 2

Source: BCPS Examination Specifications. BPS publishes no weight for oncology or rheumatology alone.

5From neutropenia to gout

Several of these look like regimen questions. Read each for the detail in the history that removes options, then weigh efficacy among what is left.

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

Case 1 of 15 · 0 answered

How case rounds work

Pick an option to see the verdict and a note on every option. Keys while the round has focus: 1–5 or A–E answer, ← → move between cases. Nothing is saved or sent anywhere.

Case 01
A 22-year-old man with osteosarcoma receives high-dose methotrexate 12 g/m² with hydration, urine alkalinization, and leucovorin rescue. At 48 hours his methotrexate level is 12 µmol/L (expected below 1 µmol/L), and SCr has risen from 0.8 to 2.4 mg/dL. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
A markedly elevated 48-hour level with acute kidney injury signals delayed methotrexate elimination, and glucarpidase rapidly cleaves circulating methotrexate, while leucovorin (dosed by level, and not given within 2 hours of glucarpidase) protects normal cells. Holding leucovorin removes the rescue that prevents fatal mucositis and myelosuppression. Conventional hemodialysis removes methotrexate poorly and does not replace leucovorin, and waiting 48 hours allows irreversible toxicity.
A
Conventional hemodialysis clears methotrexate poorly, and stopping leucovorin removes the rescue that prevents fatal toxicity.
B
Another 48 hours of exposure at this level with rising creatinine allows irreversible marrow and mucosal damage.
C
Holding leucovorin while methotrexate lingers removes rescue exactly when it is needed most.
D
Correct: glucarpidase rapidly cleaves circulating methotrexate, and leucovorin continues (spaced 2 hours from glucarpidase) to protect normal cells.
Case 02
A 58-year-old woman with seropositive rheumatoid arthritis has moderate disease activity despite methotrexate 25 mg SC weekly for 6 months. She also has relapsing-remitting multiple sclerosis, smokes, and had a myocardial infarction 2 years ago. Hepatitis B and TB screening are negative. Which medication is most appropriate to add?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
After methotrexate failure a biologic is added, and abatacept, a T-cell costimulation modulator, has no demyelination warning, so it is appropriate with her multiple sclerosis. Adalimumab and etanercept are TNF inhibitors, which can cause or worsen demyelinating disease and are contraindicated. Tofacitinib carries a boxed warning for major adverse cardiovascular events and malignancy in patients 50 or older with CV risk factors, which applies to a smoker with a prior MI.
A
Tofacitinib carries a boxed warning for cardiovascular events and malignancy in patients 50 or older with risk factors, and she smokes and had an MI.
B
TNF inhibitors such as adalimumab can trigger or worsen demyelinating disease and are avoided in multiple sclerosis.
C
Etanercept is also a TNF inhibitor, so it shares the demyelination warning that rules out this class.
D
Correct: abatacept, a T-cell costimulation modulator, has no demyelination warning and avoids the JAK inhibitor’s cardiovascular concern.
Case 03
A 65-year-old male with gout has frequent attacks despite allopurinol 300 mg daily. His serum uric acid level is 9.0 mg/dL and his creatinine clearance is 60 mL/min. Which is the most appropriate next step?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
His serum uric acid of 9.0 mg/dL is far above the treat-to-target goal of below 6 mg/dL, and frequent attacks confirm undertreatment. The ACR 2020 gout guideline favors titrating allopurinol upward from 300 mg, with monitoring, until the target is reached, even in chronic kidney disease, and a CrCl of 60 mL/min is no barrier. Switching to febuxostat or adding probenecid comes only after the first agent has been optimized, and pegloticase is reserved for gout refractory to oral therapy.
A
Correct: he remains above the uric acid target of below 6 mg/dL, and ACR 2020 favors titrating allopurinol upward, even in CKD, before switching or adding agents.
B
A uricosuric is added only after the xanthine oxidase inhibitor has been pushed to an effective dose.
C
Pegloticase is reserved for gout refractory to oral urate-lowering therapy at adequate doses.
D
Febuxostat 40 mg lowers urate no more than optimized allopurinol and carries a boxed cardiovascular warning, so switching is premature.
Case 04
A 52-year-old man has psoriatic arthritis with five swollen joints and plaque psoriasis covering 15% of his body surface area despite methotrexate 20 mg weekly for 4 months. He has HFrEF (LVEF 30%, NYHA class III) and no inflammatory bowel disease. TB screening is negative. Which medication is most appropriate to add?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
An IL-17 inhibitor such as secukinumab treats both the joint and the extensive skin disease and is appropriate when a TNF inhibitor should be avoided. Adalimumab would otherwise be a standard choice, but TNF inhibitors can worsen heart failure and are contraindicated in NYHA class III–IV HF. Apremilast is less effective for active polyarthritis and extensive psoriasis, and hydroxychloroquine has no meaningful efficacy in psoriatic arthritis and may flare psoriasis.
A
Apremilast is an oral option for milder disease but is less effective for active polyarthritis plus psoriasis over 15% of the body.
B
Correct: an IL-17 inhibitor treats both the joints and the extensive skin disease and avoids the TNF inhibitor problem in advanced heart failure.
C
Hydroxychloroquine has no meaningful efficacy in psoriatic arthritis and may flare psoriasis.
D
TNF inhibitors can worsen heart failure and are contraindicated with NYHA class III–IV symptoms.
Case 05
A 7-year-old boy receiving induction chemotherapy for acute lymphoblastic leukemia has a temperature of 38.6°C. He is hemodynamically stable. Labs: WBC 1,800 cells/mm³ with 10% segmented neutrophils and 5% bands. What is his ANC, and which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
ANC = WBC × (segs + bands) = 1,800 × 0.15 = 270 cells/mm³, which is severe neutropenia; with fever this is a medical emergency requiring empiric antipseudomonal beta-lactam therapy such as cefepime within an hour. The 180 value omits bands, and outpatient oral therapy is not appropriate for a high-risk child during induction. Using the total WBC ignores the differential, and growth factors do not replace prompt antibiotics.
A
Using the total WBC as the ANC ignores the differential; his neutrophils make up only 15% of that count.
B
180 counts segs but omits bands, and outpatient oral therapy is unsafe for a febrile child in induction chemotherapy.
C
The ANC is right, but growth factors never replace prompt empiric antibiotics in febrile neutropenia.
D
Correct: ANC = 1,800 × (0.10 + 0.05) = 270 cells/mm³; fever with severe neutropenia needs IV antipseudomonal therapy such as cefepime within an hour.
Case 06
A 63-year-old woman with metastatic colorectal cancer is starting bolus fluorouracil with leucovorin (Mayo regimen) on days 1–5 every 4 weeks. She has no oral lesions. Which measure is most appropriate to prevent oral mucositis?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
Oral cryotherapy (ice chips held in the mouth for about 30 minutes starting just before each bolus) causes local vasoconstriction during the short half-life of bolus 5-FU and is recommended by MASCC/ISOO to prevent mucositis. Palifermin is approved for mucositis prevention with high-dose chemotherapy and total body irradiation before stem cell transplant, not for 5-FU regimens. Chlorhexidine rinses are recommended against for mucositis prevention, and fluconazole prevents candidiasis, not mucositis.
A
Chlorhexidine rinses do not prevent chemotherapy-induced mucositis and are not recommended for that purpose.
B
Palifermin is approved for high-dose regimens before stem cell transplant, not for outpatient bolus 5-FU.
C
Correct: ice chips held in the mouth during each short bolus constrict oral blood flow while 5-FU levels peak, the MASCC/ISOO-recommended prevention.
D
Fluconazole prevents oral candidiasis, not the mucosal injury caused by fluorouracil.
Case 07
A 64-year-old man with metastatic melanoma receives pembrolizumab every 3 weeks. Before cycle 5 he reports 5 more stools per day than his baseline, with mild cramping but no blood, fever, or dehydration. C. difficile and stool cultures are negative. Which action is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
An increase of 4–6 stools per day over baseline is grade 2 immune-mediated diarrhea and colitis. ASCO guidance is to hold the checkpoint inhibitor and start a corticosteroid such as prednisone about 1 mg/kg/day unless the diarrhea is transient, tapering over 4–6 weeks once improved. Continuing treatment with loperamide alone risks progression and perforation, and supportive care alone undertreats an established immune-mediated process. Infliximab is reserved for steroid-refractory colitis, and permanent discontinuation is for the most severe events.
A
Infliximab is for steroid-refractory colitis, and permanent discontinuation is reserved for the most severe grades, not this one.
B
Correct: 4–6 stools over baseline is grade 2, and ASCO guidance is to hold pembrolizumab and start prednisone about 1 mg/kg/day unless symptoms are transient.
C
Holding the drug is right, but supportive care alone undertreats an established immune-mediated colitis at grade 2.
D
Continuing the checkpoint inhibitor with loperamide alone risks progression to severe colitis and perforation.
Case 08
A 24-year-old woman with systemic lupus erythematosus has biopsy-proven class IV lupus nephritis: proteinuria 3.2 g/day, SCr 1.2 mg/dL, active sediment. She takes hydroxychloroquine and wants to preserve fertility; she uses an IUD. Which induction regimen is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
KDIGO 2024 recommends glucocorticoids plus mycophenolate (or low-dose IV cyclophosphamide, or a triple regimen with belimumab or voclosporin) for class IV lupus nephritis, and mycophenolate is equally effective without cyclophosphamide’s gonadal toxicity, so it fits her wish to preserve fertility; hydroxychloroquine is continued. High-dose monthly cyclophosphamide (NIH regimen) causes premature ovarian failure. Azathioprine is a maintenance option with weaker induction efficacy, and hydroxychloroquine alone does not treat proliferative nephritis.
A
The high-dose NIH cyclophosphamide regimen works but causes premature ovarian failure, which conflicts with her fertility goal.
B
Correct: mycophenolate with glucocorticoids is a KDIGO 2024 induction regimen for class IV nephritis and spares her ovaries; hydroxychloroquine continues.
C
Azathioprine is a maintenance option with weaker induction efficacy for proliferative nephritis.
D
Hydroxychloroquine is background therapy for every lupus patient but cannot induce remission of class IV nephritis on its own.
Case 09
A 58-year-old man with diffuse large B-cell lymphoma had a complete response to six cycles of R-CHOP, but biopsy confirms relapse 7 months after completing therapy. ECOG performance status is 0, and organ function is normal. Which treatment is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
Relapse within 12 months of first-line chemoimmunotherapy is primary refractory or early relapsed disease, and second-line CD19 CAR T-cell therapy (axicabtagene ciloleucel, ZUMA-7) improved event-free and overall survival compared with salvage chemotherapy plus autologous transplant. Salvage chemotherapy followed by transplant remains standard for relapse more than 12 months after therapy. Polatuzumab-bendamustine-rituximab is an option for transplant- or CAR T-ineligible patients, and repeating R-CHOP is unlikely to work for chemorefractory disease.
A
Repeating R-CHOP is unlikely to work when lymphoma returns within months of finishing it.
B
Polatuzumab-bendamustine-rituximab is reserved for patients who cannot receive transplant or CAR T-cell therapy, and he is fit for both.
C
Salvage chemotherapy then autologous transplant stays standard for relapse beyond 12 months, but it lost to CAR T-cell therapy in early relapse.
D
Correct: relapse within 12 months of R-CHOP is early relapse, where second-line axicabtagene ciloleucel improved event-free and overall survival (ZUMA-7).
Case 10
A 61-year-old woman received axicabtagene ciloleucel 3 days ago. She now has temperature 39.6°C and BP 86/52 mm Hg that rose to 104/66 mm Hg after a 1-L fluid bolus, with SpO2 95% on room air (grade 2 cytokine release syndrome). Her neurologic examination and ICE score (10/10) are normal. Acetaminophen has been given. Which treatment is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Grade 2 CRS (fever with fluid-responsive hypotension) is treated with the IL-6 receptor antagonist tocilizumab 8 mg/kg (maximum 800 mg), which can be repeated; dexamethasone is added if CRS does not improve or worsens. Dexamethasone alone is the tempting choice, but it is the primary treatment for neurotoxicity (ICANS), which she does not have, rather than first-line therapy for CRS. Anakinra is used for CRS or ICANS refractory to tocilizumab and steroids, and high-dose methylprednisolone is reserved for grade 4 or life-threatening toxicity.
A
Correct: grade 2 CRS with fluid-responsive hypotension is treated with the IL-6 receptor blocker tocilizumab 8 mg/kg, which can be repeated.
B
Anakinra is held for CRS or neurotoxicity that does not respond to tocilizumab and corticosteroids.
C
Dexamethasone is first-line for ICANS, which she does not have, and is only added for CRS that fails to improve.
D
Pulse methylprednisolone is reserved for grade 4 or life-threatening toxicity.
Case 11
A 30-year-old woman had a complete hydatidiform mole evacuated 8 weeks ago. Her hCG has plateaued and then risen over 3 weeks, and low-risk gestational trophoblastic neoplasia (FIGO score 3, no metastases) is diagnosed. She has CKD from lupus nephritis with CrCl 38 mL/min. She wants to preserve fertility. Which treatment is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
Low-risk GTN is cured with single-agent chemotherapy that preserves fertility, and both methotrexate and actinomycin D are first-line; because methotrexate is renally cleared and accumulates at CrCl 38 mL/min, actinomycin D is preferred here. Methotrexate would otherwise be the usual choice and is the tempting answer. EMA-CO is reserved for high-risk disease (FIGO score 7 or higher), and cisplatin-based regimens are salvage options for resistant disease.
A
Cisplatin-based combinations are salvage therapy for resistant disease and are nephrotoxic in her CKD.
B
Methotrexate is the usual first-line choice, but it is renally cleared and accumulates at a CrCl of 38 mL/min.
C
Correct: single-agent actinomycin D cures low-risk GTN, preserves fertility, and avoids methotrexate’s renal accumulation.
D
EMA-CO is a multi-agent regimen for high-risk disease with a FIGO score of 7 or more.
Case 12
An 8-year-old boy (28 kg) with severe atopic dermatitis and moderate persistent asthma (on fluticasone) is starting dupilumab 300 mg SC every 4 weeks. His immunizations are up to date except the second MMR dose, which is due. Which counseling point is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
Conjunctivitis and keratitis are the most common adverse effects of dupilumab in atopic dermatitis, so families should report eye symptoms promptly. Live vaccines such as MMR should be avoided during dupilumab therapy, so the second dose should be given before starting if possible. Dupilumab needs no routine laboratory monitoring, and inhaled corticosteroids should not be stopped abruptly when it starts, even though it also treats asthma.
A
Live vaccines such as MMR should be avoided during dupilumab therapy, so the second dose belongs before the first injection.
B
Dupilumab also helps asthma, but inhaled steroids must not be stopped abruptly when it begins.
C
Correct: conjunctivitis and keratitis are dupilumab’s most common adverse effects in atopic dermatitis, so eye symptoms need a prompt report.
D
Dupilumab requires no routine blood monitoring, so monthly CBCs and liver tests add cost without value.
Case 13
A 78-year-old man is newly diagnosed with AML (no FLT3, IDH1 or IDH2 mutation). His ECOG performance status is 2, and he has HFrEF with LVEF 35% and CrCl 48 mL/min. He wants treatment aimed at remission but is not a candidate for intensive chemotherapy. Which regimen is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
For newly diagnosed AML in patients unfit for intensive chemotherapy, venetoclax plus azacitidine improved remission rates and overall survival compared with azacitidine alone (VIALE-A). 7+3 and liposomal daunorubicin-cytarabine are intensive induction regimens, and their anthracycline component is a particular problem with an LVEF of 35%. Hydroxyurea only lowers the white count for palliation and does not produce remission.
A
Liposomal daunorubicin-cytarabine is still intensive induction and delivers an anthracycline to a heart with an LVEF of 35%.
B
Hydroxyurea only lowers the white count for palliation and cannot achieve the remission he wants.
C
Correct: venetoclax plus azacitidine raised remission rates and survival in adults unfit for intensive induction (VIALE-A).
D
7+3 is intensive chemotherapy he cannot tolerate, and daunorubicin is cardiotoxic with his reduced ejection fraction.
Case 14
A 6-year-old girl with systemic juvenile idiopathic arthritis on prednisone 1 mg/kg/day develops persistent fever, hepatosplenomegaly and falling counts. Labs: ferritin 18,500 ng/mL, platelets 92,000 cells/mm³ (from 410,000), fibrinogen 120 mg/dL, AST 210 units/L, triglycerides 340 mg/dL. Macrophage activation syndrome is diagnosed. Which medication is most appropriate to add?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Macrophage activation syndrome complicating sJIA is treated with high-dose glucocorticoids plus the IL-1 receptor antagonist anakinra, which the 2021 ACR guideline for systemic JIA supports because it controls IL-1-driven hyperinflammation quickly. Tocilizumab is the tempting alternative because it treats sJIA, but IL-6 blockade can mask MAS (suppressing fever and CRP) and is not the preferred treatment for active MAS. TNF inhibitors such as etanercept and methotrexate are ineffective for the systemic features of sJIA and MAS.
A
Correct: high-dose anakinra, an IL-1 receptor antagonist, added to glucocorticoids is the preferred treatment for MAS complicating systemic JIA.
B
Methotrexate has little effect on the systemic features of sJIA and does nothing for MAS.
C
Tocilizumab treats sJIA, but IL-6 blockade can mask MAS by blunting fever and CRP and is not preferred for active MAS.
D
TNF inhibitors are ineffective against the IL-1–driven hyperinflammation of MAS.
Case 15
A 72-year-old man with metastatic castration-resistant prostate cancer is on leuprolide (testosterone below 50 ng/dL) and declines chemotherapy. He has a history of epilepsy with a seizure 6 months ago. BP is 128/78 mm Hg, K 4.3 mEq/L, and liver enzymes are normal. He has not received any androgen-pathway agent. Which treatment is most appropriate to add?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
Abiraterone with prednisone improves survival in mCRPC and, unlike enzalutamide, does not lower the seizure threshold, so it suits a patient with recent seizures; BP, K and liver enzymes must be monitored because of mineralocorticoid excess and hepatotoxicity. Enzalutamide also improves survival but carries a seizure warning and is generally avoided with a seizure history. ADT must continue in castration-resistant disease, and first-generation bicalutamide gives no survival benefit at this stage.
A
Enzalutamide improves survival but lowers the seizure threshold, and he had a seizure 6 months ago.
B
A first-generation antiandrogen gives no survival benefit in castration-resistant disease.
C
Correct: abiraterone with prednisone improves survival without enzalutamide’s seizure risk; his normal BP, potassium and liver tests allow it, with monitoring.
D
Androgen deprivation must continue in castration-resistant disease, and enzalutamide still carries the seizure problem.

6Asked about this domain

Is transplant immunosuppression on the BCPS exam?

Transplant is not a named area in the BCPS content outline, so this site has no transplant category. Immunosuppressant levels and counseling can still appear under Domain 2.

How deep does oncology go on a generalist exam?

BPS does not publish disease-level weights. Our estimate for oncology, hematology and immunology combined is about 3%, built from BPS job-analysis ratings, so prioritize emergencies, toxicity grading and supportive care over regimen detail. The practice set filtered to oncology and immunology mixes these cases with other domains.

Does drug allergy belong to this domain?

Yes. BPS names the area Allergy, Immunology, and Rheumatology (1C6). Choosing an antibiotic around a reported allergy is also an infectious diseases skill, so expect the two to meet.

Are anemias and other hematology topics part of this domain?

Yes. BPS names the area Oncology and Hematology (1C1), and this site files anemias and other blood disorders here alongside cancer supportive care. Anticoagulation for clots sits with cardiology instead.

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