Question:
60-year old male with RA on MTX for 5 years presents with SOB and cough. Chest examination reveals end-inspiratory crackles. HRCT shows reticular opacities and traction bronchiectasis (UIP pattern). Which of the following is correct?
60-year old male with RA on MTX for 5 years presents with SOB and cough. Chest examination reveals end-inspiratory crackles. HRCT shows reticular opacities and traction bronchiectasis (UIP pattern). Which of the following is correct?
Show Hint
Remember that the UIP pattern in RA-ILD carries a worse prognosis compared to the NSIP pattern. While MTX can cause hypersensitivity pneumonitis, patients with RA-ILD should not automatically have their MTX discontinued unless acute MTX toxicity is definitively suspected, as RA-ILD is generally a manifestation of the disease itself.
Updated On: Sep 3, 2026
- Methotrexate induced fibrosis is very common
- Honey combing on CT is suggestive of irreversible damage
- End inspiratory coarse crepitations are a typical finding
- This condition is likely to respond well to steroids
Show Solution
Verified By Collegedunia
The Correct Option is B
Solution and Explanation
Concept:
This question tests the understanding of Rheumatoid Arthritis-associated Interstitial Lung Disease (RA-ILD) and its differentiation from drug-induced lung injury.
The patient presents with progressive respiratory symptoms and High-Resolution Computed Tomography (HRCT) findings consistent with a Usual Interstitial Pneumonia (UIP) pattern, which is the most common radiographic and histologic pattern in RA-ILD.
Explanation:
• Rheumatoid arthritis frequently involves the lungs, with ILD being a leading cause of morbidity and mortality. The UIP pattern is characterized by subpleural, basal-predominant reticular opacities, traction bronchiectasis, and honeycombing.
• Option (A) is incorrect. Methotrexate (MTX) pneumonitis is a known but rare complication (hypersensitivity reaction), usually occurring early in the course of treatment, not as a chronic progressive fibrotic UIP pattern after 5 years. Chronic fibrosis is primarily driven by the underlying RA, not the MTX.
• Option (B) is correct. Honeycombing on an HRCT represents end-stage destruction of alveolar architecture and cystic spaces lined by bronchiolar epithelium. It is the hallmark of established, irreversible fibrosis.
• Option (C) is incorrect. The characteristic physical examination finding in fibrotic ILD (especially UIP) is fine, "Velcro-like" end-inspiratory crackles, not coarse crepitations (which are more typical of airway secretions or bronchiectasis alone).
• Option (D) is incorrect. The UIP pattern in RA-ILD (and idiopathic pulmonary fibrosis) is notoriously resistant to corticosteroid therapy. Steroids are minimally effective for established fibrosis and may carry high side-effect profiles without altering the disease course. Antifibrotics (like Nintedanib) or specific immunosuppressants are preferred.
Final answer:
The presence of honeycombing indicates severe structural lung damage and irreversible fibrosis, making (B) the correct statement.
This question tests the understanding of Rheumatoid Arthritis-associated Interstitial Lung Disease (RA-ILD) and its differentiation from drug-induced lung injury.
The patient presents with progressive respiratory symptoms and High-Resolution Computed Tomography (HRCT) findings consistent with a Usual Interstitial Pneumonia (UIP) pattern, which is the most common radiographic and histologic pattern in RA-ILD.
Explanation:
• Rheumatoid arthritis frequently involves the lungs, with ILD being a leading cause of morbidity and mortality. The UIP pattern is characterized by subpleural, basal-predominant reticular opacities, traction bronchiectasis, and honeycombing.
• Option (A) is incorrect. Methotrexate (MTX) pneumonitis is a known but rare complication (hypersensitivity reaction), usually occurring early in the course of treatment, not as a chronic progressive fibrotic UIP pattern after 5 years. Chronic fibrosis is primarily driven by the underlying RA, not the MTX.
• Option (B) is correct. Honeycombing on an HRCT represents end-stage destruction of alveolar architecture and cystic spaces lined by bronchiolar epithelium. It is the hallmark of established, irreversible fibrosis.
• Option (C) is incorrect. The characteristic physical examination finding in fibrotic ILD (especially UIP) is fine, "Velcro-like" end-inspiratory crackles, not coarse crepitations (which are more typical of airway secretions or bronchiectasis alone).
• Option (D) is incorrect. The UIP pattern in RA-ILD (and idiopathic pulmonary fibrosis) is notoriously resistant to corticosteroid therapy. Steroids are minimally effective for established fibrosis and may carry high side-effect profiles without altering the disease course. Antifibrotics (like Nintedanib) or specific immunosuppressants are preferred.
Final answer:
The presence of honeycombing indicates severe structural lung damage and irreversible fibrosis, making (B) the correct statement.
Was this answer helpful?
0
0
Top NEET SS Medical Questions
- A liver transplant patient presents with diarrhoea, colitis, a total leukocyte count of 1800, and a positive blood CMV PCR. What is the next step in management?
- A 32-year-old male recovering from dengue fever initially showed clinical improvement but now presents with recurrence of high-grade fever, fatigue, and pancytopenia on day 10 of illness. He is hemodynamically stable with no bleeding manifestations. Which of the following investigations should be performed first to evaluate the cause of relapse and cytopenia?
- A 48-year-old man with chronic hepatitis C infection is being evaluated for risk factors associated with progression of liver disease. He has a 20-year history of infection, drinks alcohol occasionally, and has a high serum HCV RNA viral load. Which of the following factors is not associated with an increased risk of progression of liver disease in chronic HCV infection?
- A 28-year-old veterinary worker who previously received a full 3-dose pre-exposure rabies vaccination series is bitten by a stray dog while handling an animal in the clinic. The wound is cleaned immediately. What is the most appropriate post-exposure management?
- A 42-year-old patient undergoing chemotherapy for acute myeloid leukemia develops neutropenia (ANC $<$ 500) and is treated with broad-spectrum antibiotics. After initial recovery of neutrophil counts (ANC = 1500), he again develops high-grade fever and right upper quadrant abdominal pain. Imaging shows multiple small hypodense lesions in the liver and spleen. What is the most likely diagnosis?
View More Questions
Top NEET SS Rheumatology Questions
- A 7-year-old unvaccinated child presents with a history of sore throat and fever 3 weeks ago. The child now develops nasal regurgitation of fluids, facial deviation, and tongue weakness with numbness. On examination, there is palatal paralysis and a nasal twang to the voice. What is the most likely diagnosis?
- A 45-year-old woman with long-standing rheumatoid arthritis (RA) develops numbness, paresthesia, non-healing leg ulcers, and absent ankle reflexes. She is on regular RA treatment. What is the most probable diagnosis?
- Rapidly progressive interstitial lung disease is associated with which of the following myositis specific antibodies?
- 42-year-old female, with diffuse cutaneous systemic sclerosis, presents with SOB/cough. CXR shows ILD. FVC 50% predicted, DLCO 30% predicted. ECG and imaging shows right ventricular enlargement and dilated PA s/o pulmonary hypertension. Most appropriate next step in management is?
- A young male presents with rapidly worsening kidney function. Urinalysis shows hematuria, 3+ proteinuria, and red blood cell casts. His serum creatinine is 3.2 mg/dL. Chest imaging reveals bilateral pulmonary nodules. Which of the following is the most appropriate initial management?
View More Questions
Top NEET SS Questions
- A liver transplant patient presents with diarrhoea, colitis, a total leukocyte count of 1800, and a positive blood CMV PCR. What is the next step in management?
- A 32-year-old male recovering from dengue fever initially showed clinical improvement but now presents with recurrence of high-grade fever, fatigue, and pancytopenia on day 10 of illness. He is hemodynamically stable with no bleeding manifestations. Which of the following investigations should be performed first to evaluate the cause of relapse and cytopenia?
- A 48-year-old man with chronic hepatitis C infection is being evaluated for risk factors associated with progression of liver disease. He has a 20-year history of infection, drinks alcohol occasionally, and has a high serum HCV RNA viral load. Which of the following factors is not associated with an increased risk of progression of liver disease in chronic HCV infection?
- A 28-year-old veterinary worker who previously received a full 3-dose pre-exposure rabies vaccination series is bitten by a stray dog while handling an animal in the clinic. The wound is cleaned immediately. What is the most appropriate post-exposure management?
- A 42-year-old patient undergoing chemotherapy for acute myeloid leukemia develops neutropenia (ANC $<$ 500) and is treated with broad-spectrum antibiotics. After initial recovery of neutrophil counts (ANC = 1500), he again develops high-grade fever and right upper quadrant abdominal pain. Imaging shows multiple small hypodense lesions in the liver and spleen. What is the most likely diagnosis?
View More Questions