Internal Medicine Common Rheumatologic Disorders Questions and Answers — Questions and Answers
Question 1: A 45-year-old female presents with a four-month history of symmetric pain and swelling in the small joints of her hands and wrists, accompanied by morning stiffness lasting over an hour. Laboratory tests are positive for rheumatoid factor and anti-CCP antibodies. What is the most appropriate initial disease-modifying therapy?
- Etanercept
- Hydroxychloroquine
- Methotrexate (Correct answer)
- Prednisone monotherapy
Correct answer: Methotrexate
Methotrexate is the cornerstone and initial disease-modifying antirheumatic drug (DMARD) of choice for most patients with newly diagnosed moderate-to-severe rheumatoid arthritis. [1, 3, 6] It has a proven track record of improving symptoms and slowing radiographic progression. Hydroxychloroquine is typically reserved for milder disease. Etanercept, a biologic DMARD, is generally used after an inadequate response to methotrexate. Prednisone is used for its rapid anti-inflammatory effects, often as a 'bridge' therapy until DMARDs take effect, but it is not recommended as a long-term monotherapy due to its side effect profile.
Question 2: A 72-year-old female presents with a new-onset, unilateral headache, scalp tenderness, and jaw claudication for the past month. Today, she experienced a transient, 'curtain-like' loss of vision in her right eye that lasted several minutes. Her erythrocyte sedimentation rate (ESR) is 95 mm/hr. What is the most critical immediate step in management?
- Schedule an urgent temporal artery biopsy
- Obtain an MRI of the brain and orbits
- Check a C-reactive protein (CRP) level
- Administer high-dose glucocorticoids (Correct answer)
Correct answer: Administer high-dose glucocorticoids
In a patient with suspected giant cell arteritis (GCA) presenting with visual symptoms like amaurosis fugax, immediate administration of high-dose glucocorticoids is essential to prevent permanent vision loss. [2, 9, 11] While a temporal artery biopsy is the gold standard for diagnosis, treatment should never be delayed to await the procedure. [4, 14] An MRI and CRP are part of the workup but are not the most critical immediate action when vision is threatened.
Question 3: A 28-year-old male presents with a six-month history of low back pain and stiffness that is worse in the morning and improves with activity. He notes the pain often wakes him in the second half of the night. On examination, he has tenderness over the sacroiliac joints. Which of the following physical exam maneuvers is most specifically associated with his likely diagnosis?
- Positive Phalen's test
- Limited lumbar flexion on Schober test (Correct answer)
- Presence of Heberden's nodes
- Ulnar deviation of the metacarpophalangeal joints
Correct answer: Limited lumbar flexion on Schober test
The patient's presentation is classic for inflammatory back pain, highly suggestive of ankylosing spondylitis (AS). A key physical finding in AS is limited lumbar spine flexion, which is objectively measured by the Schober test. [17, 19] Phalen's test is for carpal tunnel syndrome, Heberden's nodes are characteristic of osteoarthritis, and ulnar deviation is a finding in advanced rheumatoid arthritis.
Question 4: A 65-year-old male with stage 4 chronic kidney disease (eGFR 25 mL/min/1.73 m²) and hypertension presents with an acutely swollen, erythematous, and exquisitely tender right great toe. Aspiration of the joint fluid reveals needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate initial treatment for this acute flare?
- Indomethacin
- High-dose allopurinol
- Intra-articular glucocorticoid injection (Correct answer)
- Probenecid
Correct answer: Intra-articular glucocorticoid injection
This patient has an acute gout flare. In the setting of significant chronic kidney disease, NSAIDs like indomethacin are contraindicated due to the risk of worsening renal function. [16, 20] Allopurinol and probenecid are urate-lowering therapies used for chronic gout management and should not be initiated during an acute flare. An intra-articular glucocorticoid injection is a safe and effective first-line option for a monoarticular gout flare in a patient with contraindications to systemic therapies. [16, 22]
Question 5: A 29-year-old woman with a known history of systemic lupus erythematosus (SLE) presents with new-onset peripheral edema, foamy urine, and a blood pressure of 155/95 mmHg. Urinalysis reveals 3+ proteinuria and red blood cell casts. The presence of which autoantibody is most strongly associated with the development of this renal complication?
- Anti-histone antibody
- Anti-dsDNA antibody (Correct answer)
- Anti-Ro/SSA antibody
- Anti-centromere antibody
Correct answer: Anti-dsDNA antibody
The patient's presentation is highly suggestive of lupus nephritis. Anti-double-stranded DNA (anti-dsDNA) antibodies are highly specific for SLE, and their titers often correlate with disease activity, particularly with the presence and severity of lupus nephritis. [5, 7, 10] Anti-histone antibodies are associated with drug-induced lupus. Anti-Ro/SSA antibodies are linked to Sjögren's syndrome and neonatal lupus. Anti-centromere antibodies are characteristic of limited cutaneous systemic sclerosis.
Question 6: A 55-year-old female has a long-standing history of Raynaud's phenomenon, telangiectasias, and skin thickening limited to her hands and face. She is positive for anti-centromere antibodies. She now presents with several months of progressive dyspnea on exertion. Echocardiogram reveals elevated right ventricular systolic pressure. Which of the following complications is the most likely cause of her symptoms?
- Scleroderma renal crisis
- Pulmonary arterial hypertension (Correct answer)
- Aspiration pneumonia due to esophageal dysmotility
- Progressive interstitial lung disease
Correct answer: Pulmonary arterial hypertension
This patient's clinical picture (long-standing Raynaud's, limited skin involvement, anti-centromere antibodies) is classic for limited cutaneous systemic sclerosis. Pulmonary arterial hypertension (PAH) is a major, and often late, complication of this subtype and a leading cause of mortality. [25] While interstitial lung disease can occur, it is more common and severe in the diffuse subtype (associated with anti-Scl-70 antibodies). Scleroderma renal crisis is also much more characteristic of early, diffuse disease. [24, 28]
Internal Medicine Common Rheumatologic Disorders Questions and Answers
A 45-year-old female presents with a four-month history of symmetric pain and swelling in the small joints of her hands and wrists, accompanied by morning stiffness lasting over an hour.
Laboratory tests are positive for rheumatoid factor and anti-CCP antibodies.
What is the most appropriate initial disease-modifying therapy?