Internal Medicine Exam Common Rheumatologic Disorders 5 — Questions and Answers
Question 1: A 43-year-old woman with RA is on methotrexate 20mg/week. She develops mouth sores, macrocytic anemia, and fatigue. What is the most appropriate management?
- Discontinue methotrexate permanently
- Add folic acid 1mg daily and continue methotrexate (Correct answer)
- Switch to leflunomide
- Add vitamin B12 supplementation only
Correct answer: Add folic acid 1mg daily and continue methotrexate
Methotrexate toxicity (mucositis, megaloblastic anemia) is reduced by supplemental folic acid 1-5mg daily without significantly impairing its efficacy.
Question 2: A 35-year-old woman presents with livedo reticularis, recurrent spontaneous abortions, thrombocytopenia, and a prolonged PTT that does not correct with mixing study. Which antibody panel is most diagnostic?
- Anti-dsDNA and anti-Smith
- Lupus anticoagulant, anticardiolipin IgG/IgM, and anti-β2-glycoprotein I (Correct answer)
- Anti-Ro/SSA and anti-La/SSB
- Anti-centromere and anti-Scl-70
Correct answer: Lupus anticoagulant, anticardiolipin IgG/IgM, and anti-β2-glycoprotein I
Antiphospholipid syndrome is diagnosed by the combination of clinical criteria (thrombosis or pregnancy morbidity) and confirmed positive antiphospholipid antibodies on two occasions 12 weeks apart.
Question 3: A 72-year-old woman on long-term prednisone for polymyalgia rheumatica presents with sudden severe back pain. Spine X-ray shows a wedge compression fracture at T12. What is the most important preventive measure that should have been initiated?
- Calcium and vitamin D supplementation plus bisphosphonate therapy (Correct answer)
- Calcitonin nasal spray alone
- Testosterone therapy
- Teriparatide as first-line for all steroid users
Correct answer: Calcium and vitamin D supplementation plus bisphosphonate therapy
Glucocorticoid-induced osteoporosis prevention requires calcium, vitamin D, and a bisphosphonate (or other anti-resorptive) starting with chronic steroid use.
Question 4: A 58-year-old woman with RA presents with a painless effusion in her right knee. Joint aspiration yields 80 mL of clear, straw-colored fluid with WBC 1,200/mm³ and glucose equal to serum. What does this synovial fluid analysis indicate?
- Septic arthritis
- Noninflammatory (Group I) fluid consistent with RA remission or osteoarthritis overlay (Correct answer)
- Crystal-induced arthritis
- Hemorrhagic effusion
Correct answer: Noninflammatory (Group I) fluid consistent with RA remission or osteoarthritis overlay
Noninflammatory synovial fluid (WBC <2,000/mm³, clear, normal glucose) suggests inactive RA or a concurrent non-inflammatory process like OA.
Question 5: A 29-year-old man with IBD-associated arthritis has asymmetric oligoarthritis of large joints that parallels bowel disease activity. Which treatment is most appropriate for both his arthritis and bowel disease?
- Etanercept
- Infliximab (Correct answer)
- Adalimumab only for joints
- Methotrexate alone
Correct answer: Infliximab
Infliximab (anti-TNF chimeric antibody) is effective for both IBD and its associated peripheral arthritis, making it the preferred biologic in this setting.
Question 6: A 66-year-old woman presents with symmetric polyarthritis, bilateral parotid enlargement, hypercalcemia, and hilar lymphadenopathy on CXR. Serum ACE level is elevated. Which rheumatologic manifestation is most common in this condition?
- Dactylitis
- Acute migratory polyarthritis (Löfgren syndrome) (Correct answer)
- Sacroiliitis
- Erosive small joint arthritis
Correct answer: Acute migratory polyarthritis (Löfgren syndrome)
Löfgren syndrome (acute arthritis, erythema nodosum, bilateral hilar adenopathy) is the most common rheumatologic presentation of sarcoidosis and carries an excellent prognosis.
Question 7: A 48-year-old woman presents with muscle weakness, dysphagia, and anti-Jo-1 antibody positivity. Pulmonary function tests show a restrictive pattern. What is the most likely pulmonary complication?
- Pulmonary arterial hypertension
- Interstitial lung disease (Correct answer)
- Pleural effusion
- Bronchiectasis
Correct answer: Interstitial lung disease
Anti-Jo-1 antibody (antisynthetase syndrome) is strongly associated with interstitial lung disease, which is the leading cause of morbidity and mortality in polymyositis/dermatomyositis.
Internal Medicine Exam Common Rheumatologic Disorders 5
A 43-year-old woman with RA is on methotrexate 20mg/week.
She develops mouth sores, macrocytic anemia, and fatigue.
What is the most appropriate management?