Internal Medicine Exam Common Rheumatologic Disorders 4 — Questions and Answers
Question 1: A patient with RA fails methotrexate monotherapy. Anti-CCP antibodies are strongly positive. Before starting a TNF inhibitor, which screening test is absolutely required?
- HIV testing
- Tuberculin skin test or IGRA for latent TB (Correct answer)
- Hepatitis C antibody
- Echocardiogram
Correct answer: Tuberculin skin test or IGRA for latent TB
TNF inhibitors cause reactivation of latent tuberculosis, so screening with TST or IGRA and treating latent TB before initiation is mandatory.
Question 2: A 55-year-old woman with limited cutaneous systemic sclerosis has esophageal dysmotility and Raynaud's phenomenon. Which antibody is most specific for CREST syndrome?
- Anti-Scl-70 (anti-topoisomerase I)
- Anti-centromere antibody (Correct answer)
- Anti-Jo-1
- Anti-RNA polymerase III
Correct answer: Anti-centromere antibody
Anti-centromere antibody is highly specific for limited cutaneous systemic sclerosis (CREST syndrome) and associated with a better prognosis than diffuse disease.
Question 3: A 45-year-old man with gout fails allopurinol due to severe hypersensitivity reaction. His eGFR is 35 mL/min. Which urate-lowering agent is preferred?
- Febuxostat (Correct answer)
- Probenecid
- Rasburicase
- Pegloticase
Correct answer: Febuxostat
Febuxostat is a non-purine xanthine oxidase inhibitor that can be used in patients with allopurinol hypersensitivity and is safer than probenecid in CKD.
Question 4: A 38-year-old woman presents with diffuse alveolar hemorrhage, glomerulonephritis, and positive c-ANCA (PR3-ANCA). Renal biopsy shows pauci-immune crescentic GN. What is the induction therapy?
- Azathioprine + prednisone
- Cyclophosphamide + high-dose glucocorticoids (Correct answer)
- Mycophenolate mofetil + rituximab
- Plasmapheresis alone
Correct answer: Cyclophosphamide + high-dose glucocorticoids
Granulomatosis with polyangiitis (Wegener's) with organ-threatening disease requires induction with cyclophosphamide plus high-dose glucocorticoids (or rituximab as alternative).
Question 5: A 62-year-old man presents with bilateral hip pain that worsens with activity. X-ray shows joint space narrowing, subchondral sclerosis, and osteophytes. Laboratory workup is normal. Which pharmacologic therapy is first-line?
- Methotrexate
- Acetaminophen or NSAIDs (Correct answer)
- Hydroxychloroquine
- Prednisone 10mg daily
Correct answer: Acetaminophen or NSAIDs
Osteoarthritis first-line pharmacologic therapy includes acetaminophen for mild pain and NSAIDs for more severe symptoms, as DMARDs have no role.
Question 6: A 50-year-old woman with SLE develops a blood pressure of 170/110 mmHg, serum creatinine rising to 2.8 mg/dL, and thrombocytopenia. Anti-dsDNA is markedly elevated. Which intervention is most urgently needed?
- Increase hydroxychloroquine dose
- Start high-dose methylprednisolone IV pulse therapy (Correct answer)
- Initiate plasmapheresis immediately
- Start labetalol for hypertension only
Correct answer: Start high-dose methylprednisolone IV pulse therapy
Active lupus nephritis with rising creatinine and serologic flare requires prompt initiation of high-dose IV methylprednisolone pulse therapy followed by cyclophosphamide or mycophenolate.
Question 7: A patient with ankylosing spondylitis has failed two NSAIDs over 4 weeks each. Which biologic class is first-line for axial spondyloarthropathy?
- Anti-IL-6 agents (tocilizumab)
- TNF inhibitors or IL-17 inhibitors (Correct answer)
- Anti-IL-12/23 agents (ustekinumab)
- CTLA4-Ig (abatacept)
Correct answer: TNF inhibitors or IL-17 inhibitors
TNF inhibitors (etanercept, adalimumab, infliximab) and IL-17 inhibitors (secukinumab, ixekizumab) are the approved first-line biologics for NSAID-refractory axial spondyloarthropathy.
Internal Medicine Exam Common Rheumatologic Disorders 4
A patient with RA fails methotrexate monotherapy.
Anti-CCP antibodies are strongly positive.
Before starting a TNF inhibitor, which screening test is absolutely required?