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A 67-year-old lady with known seropositive Rheumatoid Arthritis (RA) was investigated for persistent unexplained positive urine dipstick test for bilirubin, despite normal liver function tests (LFTs). She had originally presented, aged 45 years, with painful feet, minimally responsive to a non-steroidal anti-inflammatory (NSAID), indomethacin. She was found to be strongly rheumatoid factor positive (1:1280) and a diagnosis of RA was made. Initial treatment was with the disease modifying antirheuamtic drug (DMARD), sulphasalazine. Over the following years, her synovitis and erosive arthropathy became refractory to sulphasalazine and she required another DMARD, weekly intramuscular methotrexate 12.5 mg (with folic acid), corticosteroid (deflazocort 3 mg daily) and (etodolac 300 mg) to control her disease. While on these DMARDs she was monitored with 6–8 weekly monitoring of her liver, renal and bone marrow function. At a routine blood and urine monitoring visit she was found to have a positive urinary dipstick for bilirubin.

Normal in the blood, abnormal in the urine