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ABIM Rheumatology study materials
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ABIM Rheumatology practice questions

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Question 1Rheumatology content categories (not enumerated in source)

A 34-year-old woman has symmetric small-joint polyarthritis, morning stiffness lasting 90 minutes, and a positive anti-CCP antibody. Which finding most strongly supports a diagnosis of rheumatoid arthritis over other inflammatory arthritides?

  1. Prolonged morning stiffness
  2. Anti-cyclic citrullinated peptide antibody positivity Correct answer.
  3. Elevated erythrocyte sedimentation rate
  4. Symmetrical distribution of joint involvement

Explanation

Anti-CCP antibodies are highly specific for rheumatoid arthritis and add substantial diagnostic weight when present with a compatible clinical picture. Acute-phase reactants and symmetry are supportive but nonspecific features shared with many inflammatory conditions.

Question 2Rheumatology content categories (not enumerated in source)

Which extra-articular manifestation of rheumatoid arthritis is most closely associated with high-titer rheumatoid factor and long-standing erosive disease?

  1. Osteophyte formation
  2. Dactylitis
  3. Rheumatoid nodules Correct answer.
  4. Enthesitis of the Achilles tendon

Explanation

Rheumatoid nodules are a classic extra-articular feature that correlates with seropositive, erosive, long-standing disease. The other listed findings are characteristic of osteoarthritis or spondyloarthritis rather than RA.

Question 3Rheumatology content categories (not enumerated in source)

A 62-year-old man has sudden monoarthritis of the first metatarsophalangeal joint with marked erythema. Joint aspiration shows needle-shaped, negatively birefringent crystals. Which diagnosis is correct?

  1. Gout Correct answer.
  2. Septic arthritis
  3. Reactive arthritis
  4. Calcium pyrophosphate deposition disease

Explanation

Needle-shaped, negatively birefringent crystals are monosodium urate and establish the diagnosis of gout. CPPD crystals are rhomboid and positively birefringent, and septic arthritis would show organisms or a sterile inflammatory effusion without crystals.

Question 4Rheumatology content categories (not enumerated in source)

Which medication should be started with low-dose aspirin and a proton pump inhibitor in a patient with newly diagnosed giant cell arteritis who has no visual symptoms?

  1. Methotrexate monotherapy
  2. Hydroxychloroquine
  3. High-dose glucocorticoids Correct answer.
  4. Colchicine

Explanation

High-dose glucocorticoids are the immediate first-line treatment for giant cell arteritis to prevent vision loss and control inflammation. Methotrexate may be used later as a steroid-sparing agent but is never monotherapy at onset.

Question 5Rheumatology content categories (not enumerated in source)

A 28-year-old woman has malar rash, photosensitivity, oral ulcers, and a positive antinuclear antibody test with anti-double-stranded DNA antibodies. Which diagnosis is most likely?

  1. Dermatomyositis
  2. Systemic lupus erythematosus Correct answer.
  3. Rheumatoid arthritis
  4. Systemic sclerosis

Explanation

The combination of malar rash, photosensitivity, oral ulcers, and anti-dsDNA antibodies fulfills clinical and immunologic criteria for systemic lupus erythematosus. Anti-dsDNA is highly specific for SLE and correlates with disease activity.

Question 6Rheumatology content categories (not enumerated in source)

Which autoantibody is most strongly associated with limited cutaneous systemic sclerosis?

  1. Anti-histidyl-tRNA synthetase (Jo-1)
  2. Anti-cyclic citrullinated peptide
  3. Anti-double-stranded DNA
  4. Anti-centromere Correct answer.

Explanation

Anti-centromere antibodies are strongly associated with the limited cutaneous form of systemic sclerosis. Anti-topoisomerase (Scl-70) is more typical of diffuse disease, and the other antibodies belong to different diseases.

Question 7Rheumatology content categories (not enumerated in source)

A patient with known gout has a serum uric acid of 5.8 mg/dL during an acute flare. How should this result be interpreted?

  1. A normal urate level reliably excludes gout
  2. Uric acid should only be measured after starting urate-lowering therapy
  3. Serum urate may be normal during an acute flare and does not exclude gout Correct answer.
  4. The result indicates the flare is not crystal-related

Explanation

Serum urate frequently falls during acute gout flares because of the acute-phase response, so a normal value does not exclude the diagnosis. Definitive diagnosis rests on synovial fluid crystal analysis.

Question 8Rheumatology content categories (not enumerated in source)

Which test is the most sensitive screening test for detecting latent tuberculosis before starting a TNF inhibitor?

  1. Erythrocyte sedimentation rate
  2. Chest radiograph alone
  3. Antinuclear antibody titer
  4. Interferon-gamma release assay Correct answer.

Explanation

Interferon-gamma release assays detect latent tuberculosis infection with high sensitivity and specificity and are preferred for screening before biologic therapy. A chest radiograph alone misses latent infection without active disease.

Question 9Rheumatology content categories (not enumerated in source)

A 45-year-old woman has proximal muscle weakness, a heliotrope rash, and Gottron papules. Which malignancy screening consideration is most appropriate?

  1. Screening is indicated only if creatine kinase is normal
  2. Screening should be deferred until after one year of immunosuppression
  3. No malignancy screening is needed because the association is limited to juvenile disease
  4. Age-appropriate cancer screening is recommended because dermatomyositis is associated with underlying malignancy Correct answer.

Explanation

Adult dermatomyositis, particularly in older patients, carries an increased risk of underlying malignancy, so age-appropriate and symptom-directed cancer screening is recommended. The association is well described in adults, not limited to juvenile disease.

Question 10Rheumatology content categories (not enumerated in source)

A 30-year-old man has asymmetric oligoarthritis, chronic low back pain, and a history of a painless penile ulcer followed by conjunctivitis. Which organism is most likely responsible?

  1. Borrelia burgdorferi
  2. Chlamydia trachomatis Correct answer.
  3. Neisseria gonorrhoeae
  4. Staphylococcus aureus

Explanation

The triad of urethritis, conjunctivitis, and reactive arthritis after a genital infection is classically triggered by Chlamydia trachomatis. The preceding painless ulcer and conjunctivitis fit this post-infectious reactive pattern.

Question 11Rheumatology content categories (not enumerated in source)

Which laboratory finding is most characteristic of antiphospholipid syndrome in a patient with recurrent venous thrombosis and fetal loss?

  1. A single low-positive antinuclear antibody
  2. Elevated complement C3
  3. Positive anti-histone antibodies
  4. Persistently positive anticardiolipin antibodies on two occasions at least 12 weeks apart Correct answer.

Explanation

Antiphospholipid syndrome requires persistent antiphospholipid antibodies, documented on two occasions at least 12 weeks apart, together with clinical events such as thrombosis or pregnancy loss. A single positive result is insufficient because transient positivity occurs.

Question 12Rheumatology content categories (not enumerated in source)

A 55-year-old woman with rheumatoid arthritis on methotrexate develops a new dry cough and progressive dyspnea. High-resolution CT shows basilar reticulation and honeycombing. Which diagnosis is most likely?

  1. Usual interstitial pneumonia Correct answer.
  2. Pneumocystis pneumonia
  3. Pleural effusion from heart failure
  4. Pulmonary embolism

Explanation

Basilar-predominant reticulation with honeycombing on high-resolution CT is the pattern of usual interstitial pneumonia, a recognized interstitial lung disease in rheumatoid arthritis. The chronic course and imaging pattern distinguish it from acute infectious or thromboembolic processes.

Question 13Rheumatology content categories (not enumerated in source)

Which feature best distinguishes polymyalgia rheumatica from rheumatoid arthritis?

  1. Predominance of shoulder and hip girdle pain with markedly elevated ESR and no peripheral synovitis Correct answer.
  2. Positive anti-CCP antibody
  3. Erosive changes of the metacarpophalangeal joints
  4. Presence of rheumatoid nodules

Explanation

Polymyalgia rheumatica presents with proximal girdle pain and stiffness with a high ESR and lacks the small-joint synovitis and erosions of rheumatoid arthritis. Anti-CCP and nodules are features of RA.

Question 14Rheumatology content categories (not enumerated in source)

A patient with systemic lupus erythematosus develops new proteinuria of 1.5 g per day. Which next step is most appropriate to guide management?

  1. Check antinuclear antibody titer
  2. Kidney biopsy Correct answer.
  3. Repeat urinalysis in six months
  4. Start high-dose aspirin

Explanation

Kidney biopsy is recommended in lupus nephritis to determine the histologic class, which guides the choice and intensity of immunosuppression. Repeat urinalysis or ANA titers do not provide the required prognostic and therapeutic information.

Question 15Rheumatology content categories (not enumerated in source)

Which physical finding is most characteristic of fibromyalgia?

  1. Synovitis of the wrists and knees
  2. Widespread pain with multiple tender points and normal inflammatory markers Correct answer.
  3. Sclerodactyly with digital ulcers
  4. Heliotrope rash of the eyelids

Explanation

Fibromyalgia is a centralized pain disorder characterized by widespread pain and tenderness without objective inflammation or elevated inflammatory markers. The other findings indicate inflammatory or connective tissue disease.

Question 16Rheumatology content categories (not enumerated in source)

A 20-year-old man has acute monoarthritis of the knee, fever, and a synovial fluid white cell count of 60,000/mm3 with a Gram stain showing gram-positive cocci. What is the most appropriate next step?

  1. Intra-articular glucocorticoid injection
  2. Empiric intravenous antibiotics and joint drainage Correct answer.
  3. Observation with repeat aspiration in 48 hours
  4. Oral colchicine

Explanation

A high synovial white cell count with gram-positive cocci on Gram stain indicates septic arthritis, which requires prompt empiric intravenous antibiotics and drainage. Delay or glucocorticoid injection risks joint destruction and systemic spread.

Question 17Rheumatology content categories (not enumerated in source)

Which medication is most appropriate for a patient with ankylosing spondylitis whose axial symptoms persist despite regular NSAID use?

  1. Hydroxychloroquine
  2. A TNF inhibitor Correct answer.
  3. Methotrexate
  4. Colchicine

Explanation

TNF inhibitors are effective for axial spondyloarthritis and are recommended when NSAIDs fail to control symptoms. Methotrexate and hydroxychloroquine have limited efficacy for axial disease.

Question 18Rheumatology content categories (not enumerated in source)

A patient on high-dose prednisone for lupus nephritis develops new-onset hyperglycemia. Which mechanism best explains this finding?

  1. Reduced renal clearance of insulin
  2. Glucocorticoid-induced insulin resistance and increased hepatic gluconeogenesis Correct answer.
  3. Destruction of pancreatic beta cells
  4. Increased insulin secretion

Explanation

Glucocorticoids cause hyperglycemia primarily by inducing insulin resistance and increasing hepatic glucose production. They do not destroy beta cells or reduce insulin clearance in the manner described.

Question 19Rheumatology content categories (not enumerated in source)

Which finding is most consistent with a diagnosis of Sjögren syndrome?

  1. Positive anti-Jo-1 antibody with mechanic's hands
  2. Positive anti-Scl-70 antibody with diffuse skin thickening
  3. Anti-centromere antibody with esophageal dysmotility
  4. Positive anti-Ro/SSA antibodies with keratoconjunctivitis sicca and xerostomia Correct answer.

Explanation

Sjögren syndrome is characterized by sicca symptoms together with anti-Ro/SSA and anti-La/SSB antibodies. The other antibody patterns belong to antisynthetase syndrome and systemic sclerosis.

Question 20Rheumatology content categories (not enumerated in source)

A patient with gout has a history of recurrent calcium oxalate kidney stones and an eGFR of 35 mL/min/1.73 m2. Which urate-lowering agent is most appropriate?

  1. Probenecid
  2. High-dose aspirin
  3. Allopurinol with dose adjustment Correct answer.
  4. Pegloticase as first-line therapy

Explanation

Allopurinol is the first-line urate-lowering agent and can be used in chronic kidney disease with dose adjustment and monitoring. Probenecid is ineffective in renal impairment and may worsen stone disease.

Question 21Rheumatology content categories (not enumerated in source)

Which pattern of joint involvement is most characteristic of osteoarthritis of the hands?

  1. Distal interphalangeal and first carpometacarpal involvement Correct answer.
  2. Dactylitis of the fingers
  3. Symmetrical proximal interphalangeal synovitis with prolonged morning stiffness
  4. Metacarpophalangeal and wrist synovitis

Explanation

Osteoarthritis of the hand classically affects the distal interphalangeal joints and the first carpometacarpal joint, producing Heberden nodes. Symmetrical MCP and PIP synovitis suggests inflammatory arthritis.

Question 22Rheumatology content categories (not enumerated in source)

A 40-year-old woman with long-standing rheumatoid arthritis develops numbness in a median nerve distribution with thenar weakness. Which complication is most likely?

  1. Cervical myelopathy from atlantoaxial subluxation
  2. Peripheral neuropathy from vasculitis
  3. Lumbosacral radiculopathy
  4. Carpal tunnel syndrome from wrist synovitis Correct answer.

Explanation

Median nerve compression at the wrist causing carpal tunnel syndrome is a common complication of rheumatoid arthritis due to wrist synovitis. Atlantoaxial subluxation would produce cervical myelopathic signs rather than isolated median nerve findings.

Question 23Rheumatology content categories (not enumerated in source)

A patient with systemic lupus erythematosus has a positive Coombs test, a hemoglobin of 8 g/dL, reticulocytosis, and an elevated indirect bilirubin. Which process best explains the anemia?

  1. Warm autoimmune hemolysis Correct answer.
  2. Aplastic crisis
  3. Iron deficiency
  4. Microangiopathic hemolysis

Explanation

A positive Coombs test with reticulocytosis and indirect hyperbilirubinemia indicates immune-mediated hemolysis, typically warm autoimmune hemolytic anemia in SLE. Microangiopathic hemolysis would show schistocytes, and iron deficiency or aplastic crisis would not produce a positive Coombs test.

Question 24Rheumatology content categories (not enumerated in source)

Which feature best distinguishes adult-onset Still disease from rheumatoid arthritis?

  1. High spiking fevers, evanescent salmon-colored rash, and markedly elevated ferritin Correct answer.
  2. Symmetrical erosive small-joint disease
  3. Positive anti-CCP antibody
  4. Rheumatoid nodules over extensor surfaces

Explanation

Adult-onset Still disease is characterized by high spiking fevers, an evanescent salmon-colored rash, and markedly elevated ferritin, features not typical of rheumatoid arthritis. Erosive small-joint disease and anti-CCP are hallmarks of RA.

Question 25Rheumatology content categories (not enumerated in source)

A patient with antisynthetase syndrome has anti-Jo-1 antibodies, myositis, and interstitial lung disease. Which additional clinical feature is most consistent with this syndrome?

  1. Gottron papules
  2. Erythema nodosum
  3. Mechanic's hands Correct answer.
  4. Heliotrope rash

Explanation

Mechanic's hands, characterized by hyperkeratotic fissuring of the lateral fingers, are a classic feature of antisynthetase syndrome. Heliotrope rash and Gottron papules are features of dermatomyositis, which overlaps but is not specific to this syndrome.

Question 26Rheumatology content categories (not enumerated in source)

Which cytokine is the principal target of tocilizumab in the treatment of rheumatoid arthritis?

  1. Tumor necrosis factor alpha
  2. Interleukin-6 receptor Correct answer.
  3. Interleukin-17A
  4. Interleukin-1 beta

Explanation

Tocilizumab is a humanized monoclonal antibody that binds the interleukin-6 receptor, blocking IL-6-mediated signaling. IL-6 is a key driver of the acute-phase response and synovial inflammation in rheumatoid arthritis.

Question 27Rheumatology content categories (not enumerated in source)

Which laboratory abnormality is a required criterion in the 2015 ACR/EULAR classification of gout?

  1. Monosodium urate crystals in synovial fluid Correct answer.
  2. Hyperuricemia above 7 mg/dL
  3. Elevated erythrocyte sedimentation rate
  4. Radiographic punched-out erosions

Explanation

Demonstration of monosodium urate crystals in synovial fluid is sufficient for classification of gout and is the reference standard. Hyperuricemia and imaging findings are supportive but not required.

Question 28Rheumatology content categories (not enumerated in source)

Which autoantibody is most specific for rheumatoid arthritis and associated with more erosive disease?

  1. Anti-histone antibody
  2. Rheumatoid factor
  3. Anti-cyclic citrullinated peptide Correct answer.
  4. Antinuclear antibody

Explanation

Anti-cyclic citrullinated peptide antibodies have high specificity for rheumatoid arthritis and predict erosive joint damage. Rheumatoid factor is more sensitive but far less specific.

Question 29Rheumatology content categories (not enumerated in source)

Which organism is the most common cause of septic arthritis in sexually active young adults?

  1. Streptococcus pyogenes
  2. Neisseria gonorrhoeae Correct answer.
  3. Staphylococcus aureus
  4. Escherichia coli

Explanation

Neisseria gonorrhoeae is the leading cause of septic arthritis in sexually active young adults, often presenting with migratory polyarthralgias and tenosynovitis. Staphylococcus aureus dominates in older adults and those with prosthetic joints.

Question 30Rheumatology content categories (not enumerated in source)

Which clinical feature is characteristic of dermatomyositis rather than polymyositis?

  1. Dysphagia
  2. Proximal muscle weakness
  3. Gottron papules over the metacarpophalangeal joints Correct answer.
  4. Elevated creatine kinase

Explanation

Gottron papules are pathognomonic cutaneous findings of dermatomyositis and are absent in polymyositis. Proximal weakness, elevated creatine kinase, and dysphagia occur in both.

Question 31Rheumatology content categories (not enumerated in source)

Which agent is first-line urate-lowering therapy in a patient with gout and a history of calcium oxalate nephrolithiasis?

  1. Allopurinol Correct answer.
  2. Pegloticase
  3. Febuxostat
  4. Probenecid

Explanation

Allopurinol is a first-line xanthine oxidase inhibitor that lowers urate production without increasing urinary uric acid excretion. Probenecid increases urinary urate and is contraindicated in stone formers.

Question 32Rheumatology content categories (not enumerated in source)

Which finding on synovial fluid analysis most strongly suggests an inflammatory rather than noninflammatory effusion?

  1. White cell count of 800/mm3
  2. White cell count of 25,000/mm3 Correct answer.
  3. Presence of monosodium urate crystals
  4. Positive Gram stain

Explanation

Inflammatory synovial fluid typically has a white cell count above 2,000/mm3, whereas noninflammatory fluid is below that threshold. A count of 25,000/mm3 falls clearly in the inflammatory range.

Question 33Rheumatology content categories (not enumerated in source)

Which clinical feature is most typical of polymyalgia rheumatica?

  1. Distal small joint synovitis with positive rheumatoid factor
  2. Symmetrical proximal muscle weakness with elevated creatine kinase
  3. Morning stiffness of the shoulders and hips with markedly elevated ESR Correct answer.
  4. Dactylitis and nail pitting

Explanation

Polymyalgia rheumatica presents with aching and morning stiffness of the shoulder and pelvic girdles accompanied by a high erythrocyte sedimentation rate. Muscle strength and creatine kinase are characteristically normal.

Question 34Rheumatology content categories (not enumerated in source)

A patient with systemic lupus erythematosus has a positive direct Coombs test, hemoglobin of 8 g/dL, reticulocytosis, and an elevated LDH with low haptoglobin. Which mechanism best explains the anemia?

  1. Bone marrow failure from chronic disease
  2. Microangiopathic destruction of red cells
  3. Warm antibody-mediated extravascular hemolysis Correct answer.
  4. Blood loss from gastrointestinal ulceration

Explanation

A positive direct Coombs test with reticulocytosis, elevated LDH, and low haptoglobin indicates immune-mediated hemolysis. In lupus, warm IgG autoantibodies cause splenic extravascular clearance of red cells.

Question 35Rheumatology content categories (not enumerated in source)

Which finding on urinalysis is most suggestive of lupus nephritis in a patient with systemic lupus erythematosus?

  1. Isolated microscopic hematuria
  2. Sterile pyuria alone
  3. Red cell casts with proteinuria Correct answer.
  4. Hyaline casts

Explanation

Red cell casts indicate glomerular bleeding and, together with proteinuria, suggest active glomerulonephritis in lupus. Hyaline casts are nonspecific and sterile pyuria alone has many causes.

Question 36Rheumatology content categories (not enumerated in source)

A 32-year-old woman has recurrent fetal loss, a prolonged PTT that does not correct with mixing, and a history of deep vein thrombosis. Which antibody is most likely responsible?

  1. Lupus anticoagulant Correct answer.
  2. Anti-beta-2 glycoprotein I IgM only
  3. Anti-Sm antibody
  4. Anticardiolipin antibody of low titer

Explanation

The lupus anticoagulant is a phospholipid-dependent antibody that prolongs the PTT and fails to correct on mixing because of an inhibitor. It is strongly associated with thrombosis and pregnancy loss.

Question 37Rheumatology content categories (not enumerated in source)

A patient with rheumatoid arthritis on methotrexate develops oral ulcers, macrocytic anemia, and elevated liver enzymes. Which intervention is most appropriate?

  1. Continue methotrexate and add folic acid
  2. Stop methotrexate and start leucovorin Correct answer.
  3. Add hydroxychloroquine
  4. Increase methotrexate dose

Explanation

These findings suggest methotrexate toxicity, which can be treated with leucovorin (folinic acid) rescue after holding the drug. Folic acid supplementation prevents but does not rescue established toxicity.

Question 38Rheumatology content categories (not enumerated in source)

A patient with ankylosing spondylitis has persistent axial symptoms despite two different NSAIDs. Which therapy is most appropriate next?

  1. Regular colchicine
  2. A TNF inhibitor Correct answer.
  3. Oral glucocorticoids at high dose
  4. Methotrexate monotherapy

Explanation

For axial spondyloarthritis with inadequate response to NSAIDs, TNF inhibitors are recommended as the next step. Methotrexate and glucocorticoids have limited efficacy for axial disease.

Question 39Rheumatology content categories (not enumerated in source)

Which pattern of joint involvement is most characteristic of hand osteoarthritis?

  1. Proximal interphalangeal sparing with isolated elbow disease
  2. Distal interphalangeal and first carpometacarpal involvement Correct answer.
  3. Metacarpophalangeal and wrist involvement
  4. Symmetrical metacarpophalangeal synovitis

Explanation

Hand osteoarthritis preferentially affects the distal interphalangeal joints, proximal interphalangeal joints, and first carpometacarpal joint. Metacarpophalangeal involvement is more typical of rheumatoid arthritis.

Question 40Rheumatology content categories (not enumerated in source)

A patient with long-standing rheumatoid arthritis develops wrist and hand numbness in a median nerve distribution with thenar atrophy. Which structure is most likely compressed?

  1. Median nerve at the carpal tunnel Correct answer.
  2. Radial nerve at the spiral groove
  3. Ulnar nerve at the cubital tunnel
  4. Posterior interosseous nerve

Explanation

Carpal tunnel syndrome results from median nerve compression at the wrist and produces numbness in the median distribution with thenar atrophy. Wrist synovitis in rheumatoid arthritis predisposes to this compression.

Question 41Rheumatology content categories (not enumerated in source)

Which test is most appropriate to confirm the diagnosis of fibromyalgia when the clinical criteria are met?

  1. No confirmatory laboratory test is required Correct answer.
  2. Electromyography
  3. Erythrocyte sedimentation rate
  4. Anti-nuclear antibody

Explanation

Fibromyalgia is a clinical diagnosis based on widespread pain and associated symptoms without an objective confirmatory test. Ancillary testing is used only to exclude alternative diagnoses.

Question 42Rheumatology content categories (not enumerated in source)

A patient with psoriatic arthritis has active peripheral arthritis and extensive plaque psoriasis. Which biologic targets both the skin and joint disease effectively?

  1. Rituximab
  2. Ustekinumab Correct answer.
  3. Belimumab
  4. Abatacept

Explanation

Ustekinumab blocks the p40 subunit shared by IL-12 and IL-23, improving both psoriatic skin disease and peripheral arthritis. Abatacept, rituximab, and belimumab are used in other autoimmune conditions.

Question 43Rheumatology content categories (not enumerated in source)

Which feature best distinguishes gout from pseudogout on synovial fluid analysis?

  1. Presence of apatite crystals
  2. Rhomboid-shaped positively birefringent crystals
  3. Needle-shaped negatively birefringent crystals Correct answer.
  4. Elevated synovial white cell count

Explanation

Gout is caused by monosodium urate crystals, which are needle-shaped and negatively birefringent under polarized light. Calcium pyrophosphate crystals in pseudogout are rhomboid and positively birefringent.

Question 44Rheumatology content categories (not enumerated in source)

A patient with antisynthetase syndrome has anti-Jo-1 antibodies, myositis, and interstitial lung disease. Which additional finding is most consistent with this syndrome?

  1. Heliotrope rash
  2. Gottron papules
  3. Shawl sign
  4. Mechanic's hands Correct answer.

Explanation

Antisynthetase syndrome is characterized by myositis, interstitial lung disease, arthritis, Raynaud phenomenon, and mechanic's hands. Heliotrope rash, Gottron papules, and shawl sign are features of dermatomyositis.

Question 45Rheumatology content categories (not enumerated in source)

Which mechanism best explains the increased fracture risk seen with chronic glucocorticoid therapy?

  1. Increased osteoclast recruitment with high bone turnover
  2. Increased renal phosphate wasting
  3. Enhanced intestinal calcium absorption
  4. Impaired osteoblast function with reduced bone formation Correct answer.

Explanation

Glucocorticoids suppress osteoblast differentiation and function, leading to reduced bone formation, which is the dominant mechanism of glucocorticoid-induced osteoporosis. They also reduce intestinal calcium absorption and increase renal calcium excretion.

Question 46Rheumatology content categories (not enumerated in source)

A patient with limited cutaneous systemic sclerosis develops new-onset hypertension, rapidly progressive renal insufficiency, and microangiopathic hemolytic anemia. Which treatment is most appropriate?

  1. Cyclophosphamide
  2. High-dose glucocorticoids
  3. Plasmapheresis alone
  4. Angiotensin-converting enzyme inhibitor Correct answer.

Explanation

These findings indicate scleroderma renal crisis, which is treated with an ACE inhibitor to control blood pressure and preserve renal function. Glucocorticoids may precipitate renal crisis and should be avoided.

Question 47Rheumatology content categories (not enumerated in source)

A patient with systemic lupus erythematosus has a positive Coombs test but a normal hemoglobin and no evidence of hemolysis. How should this finding be interpreted?

  1. It indicates a laboratory error
  2. It confirms autoimmune hemolytic anemia
  3. It predicts progression to aplastic anemia
  4. It reflects the high prevalence of autoantibodies without clinical hemolysis Correct answer.

Explanation

A positive direct Coombs test without anemia, reticulocytosis, or low haptoglobin reflects circulating autoantibodies rather than active hemolysis. In lupus, serologic positivity frequently occurs without clinical disease.

Question 48Rheumatology content categories (not enumerated in source)

A patient with rheumatoid arthritis on a TNF inhibitor develops a positive interferon-gamma release assay with a normal chest radiograph and no symptoms. Which management is most appropriate?

  1. Discontinue the TNF inhibitor permanently without further therapy
  2. Treat latent tuberculosis with rifampin-based therapy before continuing the TNF inhibitor Correct answer.
  3. Repeat the assay in six months before acting
  4. Continue the TNF inhibitor and monitor clinically

Explanation

A positive interferon-gamma release assay indicates latent tuberculosis infection, which requires treatment before or concurrent with TNF inhibitor therapy to prevent reactivation. A normal chest radiograph and absence of symptoms support latent rather than active disease.

Question 49Rheumatology content categories (not enumerated in source)

A patient with gout and chronic kidney disease has a serum urate of 9.5 mg/dL despite allopurinol at a maximally tolerated dose. Which additional agent is most appropriate?

  1. Febuxostat Correct answer.
  2. Prednisone
  3. Colchicine
  4. Probenecid

Explanation

Febuxostat is a non-purine xanthine oxidase inhibitor that can be used when allopurinol fails to achieve target urate. Probenecid is ineffective in chronic kidney disease and colchicine and prednisone treat flares rather than lowering urate.

Question 50Rheumatology content categories (not enumerated in source)

A patient with systemic lupus erythematosus develops new proteinuria of 2 g per day. Which next step is most appropriate?

  1. Kidney biopsy to guide therapy Correct answer.
  2. Start an ACE inhibitor alone
  3. Repeat urinalysis in three months
  4. Empiric high-dose cyclophosphamide

Explanation

New significant proteinuria in lupus warrants a kidney biopsy to classify the nephritis and guide immunosuppressive therapy. Treatment decisions depend on the histologic class.