ITE Rheumatology

Question 1

A 35-year-old woman presents with a 3-month history of symmetric, painful swelling of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, morning stiffness lasting 2 hours, and fatigue. Labs show RF positive, anti-CCP positive, ESR 68. Which of the following is the most appropriate initial disease-modifying therapy?

Accepted Answer

Methotrexate

Answer

Methotrexate is the anchor DMARD for rheumatoid arthritis and is first-line per ACR guidelines. Prednisone addresses symptoms but is not a DMARD. NSAIDs provide symptom relief without disease modification. Hydroxychloroquine alone is insufficient for seropositive RA with active synovitis.

Question 2

A 28-year-old woman presents with a malar rash, oral ulcers, pleuritis, and a CBC showing leukopenia (WBC 2,800) and thrombocytopenia (platelets 88,000). ANA is positive at 1:640. Which antibody, if positive, would be MOST specific for her likely diagnosis?

Accepted Answer

Anti-Smith (anti-Sm)

Answer

Anti-Smith antibody is highly specific (though not sensitive) for systemic lupus erythematosus (SLE). Anti-Ro/SSA is associated with SLE and Sjögren's but is less specific. Anti-Jo-1 is a myositis-associated antibody. Anti-Scl-70 is associated with diffuse systemic sclerosis.

Question 3

A 58-year-old man with hypertension and chronic kidney disease presents with sudden onset severe pain and swelling of the right first metatarsophalangeal joint. Synovial fluid analysis shows negatively birefringent, needle-shaped crystals. Serum uric acid is 9.4 mg/dL. He is currently on hydrochlorothiazide. What is the most appropriate acute treatment?

Accepted Answer

Colchicine 1.2 mg followed by 0.6 mg one hour later

Answer

Colchicine at the described loading dose is first-line for acute gout, especially in a patient with CKD where NSAIDs are relatively contraindicated. Allopurinol should never be started during an acute attack as it can prolong or worsen the flare. Indomethacin is effective but risky with CKD. Probenecid is a uricosuric agent for maintenance, not acute management.

Question 4

A 45-year-old woman with longstanding Raynaud's phenomenon develops progressive skin tightening extending above the elbows, dysphagia, and pulmonary hypertension. Which antibody is MOST closely associated with this presentation?

Accepted Answer

Anti-topoisomerase I (Anti-Scl-70)

Answer

Anti-Scl-70 (anti-topoisomerase I) is associated with diffuse cutaneous systemic sclerosis, which involves skin thickening proximal to the elbows and carries a higher risk of interstitial lung disease and pulmonary hypertension. Anti-centromere is associated with limited cutaneous SSc (CREST). Anti-U1 RNP is associated with mixed connective tissue disease. Anti-dsDNA is specific for SLE.

Question 5

A 32-year-old man presents with low back pain and stiffness for 8 months, worse in the morning and improving with exercise, not rest. He is HLA-B27 positive. Sacroiliac joint MRI shows bone marrow edema. Which of the following is the most appropriate initial therapy?

Accepted Answer

A nonsteroidal anti-inflammatory drug (NSAID) at full therapeutic dose

Answer

NSAIDs at full doses are first-line therapy for axial spondyloarthritis (ankylosing spondylitis) per ASAS and ACR guidelines. Methotrexate is not effective for axial disease. Anti-TNF biologics are indicated only after failure of at least two NSAIDs. Systemic corticosteroids are not recommended for axial disease.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Rheumatology