ITE Rheumatology — Questions and Answers
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?
- Methotrexate (Correct answer)
- Prednisone 40 mg daily
- Naproxen 500 mg twice daily
- Hydroxychloroquine monotherapy
Correct answer: Methotrexate
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?
- Anti-Smith (anti-Sm) (Correct answer)
- Anti-Ro/SSA
- Anti-Jo-1
- Anti-Scl-70
Correct answer: Anti-Smith (anti-Sm)
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?
- Colchicine 1.2 mg followed by 0.6 mg one hour later (Correct answer)
- Allopurinol 300 mg daily started immediately
- Indomethacin 50 mg three times daily
- Probenecid 500 mg twice daily
Correct answer: Colchicine 1.2 mg followed by 0.6 mg one hour later
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?
- Anti-topoisomerase I (Anti-Scl-70) (Correct answer)
- Anti-centromere antibody
- Anti-U1 RNP
- Anti-dsDNA
Correct answer: Anti-topoisomerase I (Anti-Scl-70)
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?
- A nonsteroidal anti-inflammatory drug (NSAID) at full therapeutic dose (Correct answer)
- Methotrexate 15 mg weekly
- Anti-TNF biologic therapy
- Systemic corticosteroids
Correct answer: A nonsteroidal anti-inflammatory drug (NSAID) at full therapeutic dose
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.
Question 6: A 70-year-old woman presents with proximal muscle weakness, difficulty rising from a chair, bilateral shoulder and hip girdle aching, an ESR of 95 mm/hr, and a CRP of 4.2 mg/dL. She has no muscle enzyme elevation and normal EMG. What is the most likely diagnosis?
- Polymyalgia rheumatica (PMR) (Correct answer)
- Polymyositis
- Fibromyalgia
- Hypothyroid myopathy
Correct answer: Polymyalgia rheumatica (PMR)
PMR presents in patients >50 with bilateral proximal girdle stiffness/aching, markedly elevated inflammatory markers, but normal CK and EMG — distinguishing it from inflammatory myopathy. Polymyositis has elevated CK and abnormal EMG. Fibromyalgia does not cause elevated ESR. Hypothyroid myopathy may elevate CK and TSH would be abnormal.
ITE Rheumatology
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?
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