ABIM Rheumatology Certification Practice Test

Most rheumatology fellows already know the diseases by the time they sit for the ABIM boards — the exam isn’t really testing whether you can name lupus. It’s testing whether you can look at a patient scenario, weigh competing clinical signals, and pick the next best action when two or three options all sound reasonable. This ABIM Rheumatology Practice Test is built around that specific skill: original, single-best-answer clinical vignettes across every major blueprint domain — rheumatoid arthritis, lupus, vasculitis, crystal arthropathies, spondyloarthritis, metabolic bone disease, and more — with detailed explanations that walk through the clinical reasoning, not just confirm the letter.

One note upfront, because ABIM takes this seriously and so should any prep resource: ABIM’s exam content is confidential and copyright-protected, and candidates specifically agree not to reconstruct or discuss actual exam content. Every question here is original material written to reflect the blueprint’s style and difficulty — not reconstructed from memory of a real exam, and not represented as anything else.

What Is the ABIM Rheumatology Certification Exam?

Most questions ask you to do something with clinical information — diagnose, interpret a test, choose a treatment, assess risk, judge prognosis, or apply pathophysiology — rather than simply recall a fact in isolation. ABIM reviews and updates this blueprint on an ongoing basis based on diplomate feedback and practice data, so the relative weight of each domain can shift slightly over time.

What’s Covered on the Exam (Blueprint Weighting)

Four domains — Other Rheumatic/Connective Tissue Disorders, RA, Lupus, and Nonrheumatic Systemic Disorders — together account for nearly half the exam. That’s a genuinely useful map for study time allocation, though it doesn’t mean the smaller domains (crystal arthropathies, metabolic bone disease) are safe to skip; a 5% domain is still 10–12 questions on a 240-item exam.

Eligibility Requirements

To sit for the ABIM Rheumatology Certification Exam, physicians must:

• Already hold ABIM certification in internal medicine
• Complete accredited rheumatology fellowship training — currently a minimum of 24 months, including at least 12 clinical months, with specified procedural experience
• Complete training through a U.S. or Canadian program accredited and recognized by ABIM
• Demonstrate clinical competence and procedural skills as required by the training program
• Maintain a valid, unrestricted medical license
• Complete all required training (including vacation time) by October 31 of the examination year to be admitted to that year’s exam

Confirm your specific status directly with ABIM before registering, since eligibility rules and deadlines can be updated.

How to Register

1. Confirm your ABIM internal medicine certification and fellowship eligibility.
2. Review current registration deadlines for your target exam administration.
3. Register through the ABIM Physician Portal.
4. Complete required application information.
5. Schedule your appointment through the designated testing provider.
6. Review ABIM’s current examination policies before test day.

How Is the Exam Scored?

ABIM uses a scaled scoring system, not a raw percent-correct threshold — its equating process accounts for difficulty differences across exam forms, so a specific percentage doesn’t translate to a universal passing standard the way it might on a fixed-form test. Rely on ABIM’s current official scoring information and your own score report rather than an unofficial percentage target circulating online.

How to Study for the ABIM Rheumatology Exam

• Start with the blueprint, not a textbook table of contents. Weight your remaining time toward Other Rheumatic/Connective Tissue Disorders, RA, Lupus, and Nonrheumatic Systemic Disorders, since together they’re nearly half the exam.
• Read current ACR guidelines directly, not just secondary summaries — several board-style questions are built to test whether you know where current guidelines actually draw a line (a treatment threshold, a monitoring interval, a first-line versus second-line choice).
• Drill high-yield discriminating pairs deliberately — gout vs. CPPD, GCA vs. PMR, infection vs. flare, drug toxicity vs. disease flare. These distinctions show up constantly because they’re clinically consequential, not because they’re obscure trivia.
• Practice recognizing when a positive antibody isn’t a diagnosis — ANA, RF, and anti-CCP positivity in isolation is a very different clinical situation than positivity plus a compatible clinical picture, and board questions frequently test that exact distinction.
• Review every incorrect answer’s full reasoning, including why the other three options are wrong — vignette-style exams often include a partially-correct-sounding distractor that requires understanding why it falls short, not just recognizing the better answer.
• Work a strong question bank twice rather than a huge volume once — repetition after a gap tends to solidify pattern recognition better than sheer breadth alone.

Exam Day Tips

• Review ABIM’s current examination policies and tutorial before your appointment, since procedures and scheduling requirements can change.
• Read the entire clinical stem before looking at answer choices — identify the actual clinical problem and what the question is asking (diagnosis? next step? mechanism?) before evaluating options.
• Don’t second-guess a well-supported answer simply because another option sounds more sophisticated or obscure — board exams frequently include a “zebra” distractor designed to tempt overthinking.
• Manage your time across the full exam rather than getting stuck defending a guess on one difficult vignette.

Common Mistakes to Avoid

• Memorizing answer patterns instead of the underlying clinical reasoning
• Treating a positive antibody test as a standalone diagnosis rather than one piece of a clinical picture
• Choosing a treatment before fully establishing the clinical problem
• Failing to distinguish infection from autoimmune inflammation in overlapping presentations
• Underweighting complications and extra-articular manifestations
• Ignoring drug toxicity and monitoring questions in favor of purely diagnostic content
• Spending excessive time defending one difficult question at the expense of the rest of the exam
• Reviewing only correct answers without understanding why the alternatives were wrong

Is the ABIM Rheumatology Exam Difficult?

It’s demanding because it combines broad disease knowledge with applied clinical judgment across a genuinely wide field — but most candidates do pass, and difficulty tends to concentrate less around recognizing diseases (which fellowship training covers thoroughly) and more around choosing the best next step when multiple options are defensible. A focused study plan built around the actual blueprint weighting, consistent vignette practice, and honest review of your reasoning errors tends to matter more than sheer volume of material covered.

ABIM Rheumatology Sample Questions and Answers

Question 1. A 46-year-old woman has had symmetric pain and swelling of the MCP and PIP joints for 4 months. She has morning stiffness lasting 2 hours and difficulty opening jars. Examination shows synovitis of the MCP and PIP joints bilaterally. ESR and CRP are elevated. Rheumatoid factor is positive, and anti–cyclic citrullinated peptide antibody is strongly positive. Radiographs show no erosions. She has no contraindications to immunosuppressive therapy. Which of the following is the most appropriate initial disease-modifying treatment?

A. Hydroxychloroquine monotherapy
B. Methotrexate with appropriate folic acid supplementation
C. Adalimumab monotherapy
D. Prednisone monotherapy for 6 months

Correct Answer: B. Methotrexate with appropriate folic acid supplementation

Answer Explanation:
Methotrexate is the preferred initial conventional disease-modifying antirheumatic drug for most patients with active rheumatoid arthritis, particularly when there is clinically significant synovitis and elevated inflammatory markers. Early treatment is important because ongoing inflammation can produce irreversible joint damage even before erosions appear on radiographs. Methotrexate is effective for controlling disease activity and reducing structural progression and is generally used with folic acid to reduce adverse effects. A treat-to-target strategy involves reassessing disease activity and adjusting therapy when remission or low disease activity is not achieved. Biologic therapy is generally considered when conventional DMARD therapy is inadequate or inappropriate. Hydroxychloroquine alone is usually insufficient for moderately active disease, while glucocorticoid monotherapy does not provide appropriate long-term disease modification.

Why the other options are incorrect:

Option A is insufficient for this degree of active inflammatory arthritis and has less disease-modifying potency than methotrexate.

Option C is not usually the preferred first-line DMARD when methotrexate is appropriate.

Option D controls inflammation temporarily but does not adequately prevent long-term rheumatoid joint damage.

Study Guide:
• Recognize symmetric inflammatory polyarthritis as a classic rheumatoid arthritis presentation.
• Anti-CCP positivity is strongly associated with rheumatoid arthritis and erosive disease risk.
• Methotrexate is the usual anchor DMARD for active rheumatoid arthritis.
• Use treat-to-target management with regular disease-activity assessment.

Question 2. A 29-year-old woman with systemic lupus erythematosus presents with edema, hypertension, and foamy urine. Urinalysis shows 3+ protein, numerous dysmorphic erythrocytes, and red blood cell casts. Serum creatinine has increased from 0.8 to 1.5 mg/dL over 2 weeks. Complement levels are low, and anti–double-stranded DNA antibody titers have increased substantially. A 24-hour urine collection shows 2.8 g of protein. Which of the following is the most appropriate next step?

A. Kidney biopsy
B. Begin NSAID therapy
C. Repeat urinalysis in 6 months
D. Start hydroxychloroquine alone

Correct Answer: A. Kidney biopsy

Answer Explanation:
This patient has clinical evidence of active lupus nephritis, including proteinuria, hematuria with dysmorphic erythrocytes and red blood cell casts, rising creatinine, hypocomplementemia, and increasing anti–double-stranded DNA antibody levels. Kidney biopsy is important because clinical findings alone cannot reliably distinguish among lupus nephritis classes, and treatment intensity depends substantially on histopathologic classification and activity/chronicity. Proliferative forms such as class III or IV lupus nephritis generally require substantial immunosuppressive therapy, whereas other classes may have different treatment strategies. Obtaining tissue before initiating definitive immunosuppression can therefore guide management when clinically feasible. Hydroxychloroquine remains important for most patients with SLE but is not adequate alone for significant active nephritis. NSAIDs are inappropriate in this setting because they may worsen renal function.

Why the other options are incorrect:

Option B can worsen kidney function and does not treat immune-mediated glomerular inflammation.

Option C delays evaluation of potentially progressive kidney disease.

Option D is useful background therapy for SLE but is inadequate as sole treatment for significant nephritis.

Study Guide:
• Dysmorphic RBCs and RBC casts indicate glomerular inflammation.
• Proteinuria plus active urinary sediment should raise concern for lupus nephritis.
• Kidney biopsy classifies lupus nephritis and guides immunosuppressive therapy.
• Hydroxychloroquine is important in SLE but does not replace induction therapy for severe nephritis.

Question 3. A 74-year-old woman develops a new unilateral temporal headache, scalp tenderness, jaw pain while chewing, and transient visual blurring. ESR and CRP are markedly elevated. She has no focal neurologic deficits. Which of the following is the most appropriate immediate management?

A. Wait for temporal artery biopsy before initiating treatment
B. Begin high-dose glucocorticoid therapy immediately
C. Start methotrexate and reassess in 2 weeks
D. Obtain MRI of the brain before treatment

Correct Answer: B. Begin high-dose glucocorticoid therapy immediately

Answer Explanation:
The presentation is highly concerning for giant cell arteritis, particularly because of new headache, scalp tenderness, jaw claudication, inflammatory marker elevation, and visual symptoms. The major immediate concern is irreversible visual loss from ischemic optic neuropathy. Treatment with high-dose glucocorticoids should therefore begin promptly when clinical suspicion is high rather than waiting for temporal artery biopsy or another confirmatory test. Temporal artery biopsy or appropriate vascular imaging can subsequently help establish the diagnosis, but treatment should not be delayed when vision is threatened. Depending on the clinical situation, intravenous glucocorticoids may be used for acute visual ischemia. Methotrexate can have a steroid-sparing role in selected patients but is not adequate initial emergency therapy.

Why the other options are incorrect:

Option A creates an unacceptable delay when permanent visual loss is possible.

Option C does not provide sufficiently rapid protection against ischemic complications.

Option D may be useful in selected differential diagnoses but should not delay treatment of suspected giant cell arteritis.

Study Guide:
• Jaw claudication is a particularly important clue to giant cell arteritis.
• Visual symptoms represent an ophthalmologic emergency.
• Start glucocorticoids immediately when clinical suspicion is high.
• Diagnostic testing should proceed without delaying treatment.

Question 4. A 38-year-old man has chronic inflammatory low back pain for 2 years. He reports prolonged morning stiffness that improves with exercise but not with rest. He also has recurrent anterior uveitis and tenderness at the Achilles insertion. Pelvic radiography shows bilateral sacroiliitis. He has already completed an adequate trial of NSAID therapy with persistent significant symptoms. Which of the following is the most appropriate next treatment?

A. Long-term prednisone
B. Methotrexate monotherapy
C. A tumor necrosis factor inhibitor
D. Hydroxychloroquine

Correct Answer: C. A tumor necrosis factor inhibitor

Answer Explanation:
This patient has axial spondyloarthritis with objective sacroiliitis, inflammatory back pain, enthesitis, and recurrent anterior uveitis. Persistent active disease despite an adequate NSAID trial is an indication for escalation to biologic therapy, and TNF inhibitors are established treatment options for active axial disease. Choice of biologic can be influenced by extra-articular manifestations. In particular, recurrent inflammatory bowel disease may favor an IL-17-independent strategy, whereas recurrent uveitis can be an important consideration when selecting biologic therapy. Methotrexate has limited effectiveness for axial disease, although it can help peripheral arthritis in selected patients. Long-term systemic glucocorticoids are not appropriate disease-modifying therapy for axial spondyloarthritis, and hydroxychloroquine has no meaningful role in controlling axial inflammation.

Why the other options are incorrect:

Option A is inappropriate as long-term therapy because systemic glucocorticoids do not adequately control axial disease and carry substantial toxicity.

Option B has limited efficacy for axial spondyloarthritis.

Option D does not treat axial spondyloarthritis.

Study Guide:
• Inflammatory back pain improves with activity rather than rest.
• Sacroiliitis, enthesitis, and anterior uveitis strongly support axial spondyloarthritis.
• NSAIDs are commonly used initially.
• Persistent active axial disease may require biologic therapy.

Question 5. A 61-year-old man presents with sudden severe pain and swelling of the first metatarsophalangeal joint that began overnight. The joint is erythematous and extremely tender. Synovial fluid analysis shows numerous needle-shaped crystals with strong negative birefringence under polarized light microscopy. There are no systemic signs of infection. Which of the following is the most appropriate treatment for this acute attack?

A. Immediate allopurinol dose escalation
B. Intra-articular glucocorticoid injection
C. Probenecid as monotherapy
D. Long-term colchicine without treatment of the acute inflammation

Correct Answer: B. Intra-articular glucocorticoid injection

Answer Explanation:
The findings establish acute gout caused by monosodium urate crystals. Needle-shaped crystals demonstrating strong negative birefringence are characteristic of monosodium urate. For an acute attack involving a single accessible joint, intra-articular glucocorticoid injection is an effective treatment option, particularly when NSAIDs or systemic glucocorticoids are undesirable. Other effective acute treatments include NSAIDs, colchicine, and systemic glucocorticoids, depending on comorbidities and timing of presentation. Urate-lowering therapy such as allopurinol is used for long-term prevention rather than as treatment for immediate pain relief. Importantly, initiation or continuation of urate-lowering therapy should be considered separately from treatment of the acute inflammatory episode. Synovial fluid examination remains important when septic arthritis is a realistic alternative diagnosis.

Why the other options are incorrect:

Option A does not rapidly control acute inflammation and may complicate an untreated attack.

Option C is a urate-lowering strategy rather than appropriate acute anti-inflammatory treatment.

Option D does not adequately address the immediate inflammatory process.

Study Guide:
• Monosodium urate crystals are needle-shaped and negatively birefringent.
• Acute gout requires rapid anti-inflammatory treatment.
• Treatment choices include NSAIDs, colchicine, glucocorticoids, and intra-articular steroids.
• Urate lowering is primarily for long-term prevention.

Question 6. A 67-year-old man with diabetes mellitus presents with acute fever and a painful swollen knee. Temperature is 38.9°C. The knee is warm and has a large effusion. Arthrocentesis produces cloudy fluid with 82,000 leukocytes/µL and 94% neutrophils. Gram stain is negative. Crystals are not seen. Which of the following is the most appropriate next step?

A. Reassure the patient because the Gram stain is negative
B. Treat as septic arthritis while awaiting culture results
C. Begin intra-articular glucocorticoids immediately
D. Diagnose rheumatoid arthritis based on the synovial leukocyte count

Correct Answer: B. Treat as septic arthritis while awaiting culture results

Answer Explanation:
This patient has a classic presentation of acute septic arthritis, with fever, a markedly inflamed monoarthritis, and highly inflammatory synovial fluid. A negative Gram stain does not exclude septic arthritis because its sensitivity is limited. Synovial fluid should be sent for Gram stain and culture, and appropriate empiric antimicrobial therapy should be initiated promptly when clinical suspicion is high, with joint drainage as appropriate. Delay can result in rapid cartilage destruction, bacteremia, and permanent functional impairment. Diabetes increases the risk of serious infection. Intra-articular glucocorticoids should not be administered until infection has been excluded. The synovial leukocyte count supports an inflammatory process but is not specific for rheumatoid arthritis and must be interpreted within the clinical context.

Why the other options are incorrect:

Option A incorrectly treats a negative Gram stain as exclusion of infection.

Option C may worsen an unrecognized joint infection.

Option D ignores the acute febrile monoarthritis and does not explain the clinical presentation.

Study Guide:
• Septic arthritis is a medical emergency requiring rapid evaluation and treatment.
• A negative Gram stain does not exclude infection.
• Obtain synovial cultures and initiate empiric antibiotics when suspicion is high.
• Prompt drainage is often an important part of management.

Question 7. A 72-year-old woman with rheumatoid arthritis has taken prednisone 7.5 mg daily for 18 months. She has no history of fragility fracture. Her DXA scan shows a femoral neck T-score of −2.6. Vitamin D level is adequate, and renal function is normal. Which of the following is the most appropriate pharmacologic therapy to reduce fracture risk?

A. Alendronate
B. Calcitonin nasal spray alone
C. Estrogen therapy solely for fracture prevention
D. No therapy because she has never fractured a bone

Correct Answer: A. Alendronate

Answer Explanation:
This patient has osteoporosis by DXA criteria and is receiving long-term glucocorticoid therapy, which further increases fracture risk. An oral bisphosphonate such as alendronate is an appropriate first-line pharmacologic option for many patients with glucocorticoid-induced osteoporosis when there are no contraindications. Management should also include adequate calcium and vitamin D intake, weight-bearing exercise as appropriate, fall-risk assessment, and minimization of glucocorticoid exposure when clinically feasible. Treatment decisions should incorporate fracture history, bone mineral density, glucocorticoid dose and duration, age, and overall fracture risk. Calcitonin is not preferred as primary therapy for osteoporosis. Estrogen has important risks and is not routinely used solely to prevent fractures in this setting.

Why the other options are incorrect:

Option B is substantially less effective as a primary osteoporosis treatment.

Option C is not routinely recommended solely for fracture prevention because of its risk profile.

Option D ignores established osteoporosis and substantial glucocorticoid-associated fracture risk.

Study Guide:
• A T-score of −2.5 or lower meets the DXA definition of osteoporosis.
• Chronic glucocorticoid exposure increases fracture risk.
• Bisphosphonates are commonly used for glucocorticoid-induced osteoporosis.
• Always address calcium, vitamin D, exercise, falls, and glucocorticoid exposure.

Question 8. A 59-year-old woman has progressive pain and stiffness in both knees that worsens after prolonged walking and improves with rest. Examination reveals crepitus and bony enlargement without warmth or significant synovitis. Radiographs demonstrate medial compartment joint-space narrowing, osteophytes, and subchondral sclerosis. She has obesity and hypertension. Which of the following is the most appropriate initial management?

A. Long-term prednisone
B. Weight loss combined with an exercise-based program
C. Methotrexate
D. Rituximab

Correct Answer: B. Weight loss combined with an exercise-based program

Answer Explanation:
The clinical and radiographic findings are typical of knee osteoarthritis. For symptomatic knee osteoarthritis, nonpharmacologic therapy is foundational and includes exercise, strengthening, physical activity, and weight reduction when overweight or obese. Weight loss can improve pain and function while reducing mechanical loading across the knee. Pharmacologic options can be added according to symptom severity, comorbidities, and treatment response. Long-term systemic glucocorticoids and disease-modifying immunosuppressive agents have no role in routine osteoarthritis treatment because osteoarthritis is not primarily an immune-mediated inflammatory synovitis. The absence of substantial warmth, prolonged inflammatory morning stiffness, and significant synovitis further supports a degenerative rather than inflammatory process.

Why the other options are incorrect:

Option A exposes the patient to systemic steroid toxicity without treating the underlying degenerative disease.

Option C is used for inflammatory rheumatic diseases and does not treat osteoarthritis.

Option D is an immunologic therapy with no role in routine osteoarthritis.

Study Guide:
• Osteoarthritis typically causes mechanical pain that worsens with activity.
• Crepitus, bony enlargement, osteophytes, and joint-space narrowing support the diagnosis.
• Exercise and weight reduction are central treatment strategies.
• Avoid unnecessary systemic immunosuppression.

Question 9. A 42-year-old woman develops progressive skin thickening of the fingers and face, Raynaud phenomenon, dysphagia, and multiple telangiectasias. Examination shows sclerodactyly and calcinosis around several fingertips. Pulmonary function testing shows a reduced diffusing capacity for carbon monoxide. Which of the following complications should be specifically monitored because of its potential to become life-threatening?

A. Pulmonary arterial hypertension
B. Septic arthritis
C. Gouty nephrolithiasis
D. Osteoarthritis of the hands

Correct Answer: A. Pulmonary arterial hypertension

Answer Explanation:
This patient has systemic sclerosis with features of limited cutaneous disease, including sclerodactyly, Raynaud phenomenon, telangiectasias, calcinosis, and gastrointestinal involvement. Pulmonary complications are major causes of morbidity and mortality in systemic sclerosis. Pulmonary arterial hypertension is an important complication and should be screened for periodically, particularly in patients with reduced diffusing capacity or other risk factors. Screening may include pulmonary function testing, echocardiography, and biomarkers, followed by right-heart catheterization when pulmonary hypertension is suspected and definitive hemodynamic assessment is required. Interstitial lung disease is another major systemic sclerosis complication and should also be evaluated. Recognizing pulmonary vascular disease early is important because treatment can substantially affect symptoms and outcomes.

Why the other options are incorrect:

Option B is not a characteristic major systemic sclerosis complication requiring routine disease-specific surveillance.

Option C is unrelated to the systemic sclerosis phenotype described.

Option D may occur but is not the life-threatening complication requiring priority surveillance.

Study Guide:
• Systemic sclerosis can involve skin, gastrointestinal tract, lungs, kidneys, and cardiovascular system.
• Pulmonary arterial hypertension is an important cause of morbidity and mortality.
• Reduced DLCO can signal pulmonary vascular or interstitial lung disease.
• Screen systematically for cardiopulmonary complications.

Question 10. A 35-year-old woman reports progressive proximal muscle weakness over 3 months. She has difficulty climbing stairs and lifting objects overhead. Examination shows violaceous discoloration around the eyelids and scaly erythematous plaques over the MCP joints. Creatine kinase is markedly elevated. Which of the following is the most likely diagnosis?

A. Polymyalgia rheumatica
B. Dermatomyositis
C. Fibromyalgia
D. Myasthenia gravis

Correct Answer: B. Dermatomyositis

Answer Explanation:
The combination of symmetric proximal muscle weakness, markedly elevated creatine kinase, heliotrope-appearing discoloration around the eyes, and characteristic Gottron papules strongly supports dermatomyositis. The weakness reflects inflammatory muscle disease rather than a primary neuromuscular junction disorder. Dermatomyositis may also have pulmonary, esophageal, and cutaneous manifestations, and adult-onset disease can be associated with malignancy depending on clinical phenotype and antibody profile. Evaluation generally includes muscle enzymes, appropriate autoantibody testing, assessment for dysphagia and respiratory involvement, and confirmation with imaging, electromyography, muscle biopsy, or skin biopsy when needed. Treatment commonly involves systemic glucocorticoids with steroid-sparing immunosuppressive therapy according to disease severity and organ involvement.

Why the other options are incorrect:

Option A usually causes shoulder and hip girdle pain and stiffness in older adults rather than objective inflammatory muscle weakness.

Option C causes widespread pain and fatigue without inflammatory muscle injury or markedly elevated CK.

Option D causes fluctuating weakness without characteristic dermatomyositis skin findings or elevated CK from muscle inflammation.

Study Guide:
• Dermatomyositis causes proximal muscle weakness plus characteristic skin manifestations.
• Gottron papules and heliotrope rash are high-yield clues.
• CK is typically elevated because of muscle injury.
• Evaluate for associated organ involvement and appropriate malignancy risk.

Question 11. A 31-year-old woman has recurrent pregnancy losses and a history of an unprovoked deep venous thrombosis. Laboratory testing repeatedly demonstrates a positive lupus anticoagulant 12 weeks apart. She is not currently pregnant. Which of the following is the most appropriate long-term antithrombotic therapy?

A. Aspirin alone
B. Warfarin with an appropriate therapeutic INR target
C. Clopidogrel alone
D. No therapy because the thrombosis occurred several years ago

Correct Answer: B. Warfarin with an appropriate therapeutic INR target

Answer Explanation:
The patient has antiphospholipid syndrome characterized by a documented thrombotic event and persistent antiphospholipid antibody positivity. Patients with antiphospholipid syndrome and prior venous thrombosis generally require long-term anticoagulation, with a vitamin K antagonist such as warfarin commonly used for secondary thrombosis prevention. Aspirin alone is inadequate for established thrombotic antiphospholipid syndrome. Direct oral anticoagulants are generally avoided in patients with high-risk antiphospholipid antibody profiles, particularly those with triple-positive antibodies or arterial thrombosis, because of concerns about recurrent thrombosis. The history of recurrent pregnancy loss provides additional evidence of the syndrome but does not replace the thrombotic indication for anticoagulation. Therapy should be individualized according to thrombotic history, antibody profile, pregnancy status, and bleeding risk.

Why the other options are incorrect:

Option A is generally insufficient secondary prevention after an established venous thromboembolism.

Option C is an antiplatelet agent and does not provide appropriate anticoagulation for this indication.

Option D leaves the patient at substantial risk for recurrent thrombosis.

Study Guide:
• Antiphospholipid syndrome requires both appropriate clinical and laboratory criteria.
• Persistent antibody positivity must be demonstrated on appropriately separated testing.
• Thrombotic APS generally requires long-term anticoagulation.
• Consider antibody profile and thrombosis type when selecting therapy.

Question 12. A 68-year-old man develops chronic sinusitis, recurrent otitis media, cough, hemoptysis, and rapidly progressive glomerulonephritis. CT of the chest shows multiple pulmonary nodules, some with cavitation. Laboratory testing shows a strongly positive cytoplasmic ANCA pattern with anti-proteinase 3 antibodies. Which of the following is the most likely diagnosis?

A. Microscopic polyangiitis
B. Granulomatosis with polyangiitis
C. Polyarteritis nodosa
D. Giant cell arteritis

Correct Answer: B. Granulomatosis with polyangiitis

Answer Explanation:
The combination of upper respiratory tract disease, pulmonary nodules with cavitation, and rapidly progressive glomerulonephritis strongly suggests granulomatosis with polyangiitis, an ANCA-associated small-vessel vasculitis. Proteinase 3 antibodies are commonly associated with GPA, although ANCA results must always be interpreted within the clinical context. Microscopic polyangiitis can also produce pulmonary-renal syndrome but typically lacks the characteristic granulomatous upper-airway disease and cavitating nodules associated with GPA. Polyarteritis nodosa primarily affects medium-sized arteries and does not typically cause glomerulonephritis because renal arteries are involved without glomerular capillaritis. Giant cell arteritis affects large and medium-sized vessels and presents primarily in older adults with cranial ischemic symptoms.

Why the other options are incorrect:

Option A can cause pulmonary-renal disease but is less characteristic of destructive upper-airway disease and cavitating nodules.

Option C does not typically cause glomerulonephritis or ANCA-associated small-vessel disease.

Option D does not explain the pulmonary-renal syndrome.

Study Guide:
• GPA classically combines ENT disease, pulmonary involvement, and glomerulonephritis.
• PR3-ANCA is strongly associated with GPA.
• Cavitating pulmonary nodules are an important clue.
• Always integrate ANCA results with clinical and tissue findings.

Question 13. A 56-year-old woman presents with dry eyes, dry mouth, fatigue, and recurrent dental caries. Examination shows decreased salivary pooling. She also has bilateral parotid enlargement. Anti-Ro/SSA antibodies are positive. Which additional complication requires particular long-term clinical vigilance?

A. Non-Hodgkin lymphoma
B. Aortic dissection
C. Acute gout
D. Osteonecrosis of the femoral head

Correct Answer: A. Non-Hodgkin lymphoma

Answer Explanation:
The patient has a classic presentation of primary Sjögren syndrome, with sicca symptoms, salivary gland enlargement, dental complications, and anti-Ro/SSA antibodies. Sjögren syndrome is associated with an increased risk of lymphoproliferative disease, particularly B-cell non-Hodgkin lymphoma. Persistent or asymmetric salivary gland enlargement, lymphadenopathy, palpable purpura, low complement levels, cryoglobulinemia, and systemic manifestations can signal increased lymphoma risk and should prompt careful evaluation. Management of Sjögren syndrome also includes aggressive ocular and oral dryness treatment and monitoring for systemic complications such as neuropathy, pulmonary disease, renal tubular abnormalities, and vasculitis. Immunosuppressive treatment is selected according to organ involvement rather than sicca symptoms alone.

Why the other options are incorrect:

Option B is not a characteristic long-term complication of Sjögren syndrome.

Option C is unrelated to the patient’s autoimmune exocrinopathy.

Option D is not a defining complication of Sjögren syndrome.

Study Guide:
• Sjögren syndrome primarily affects exocrine glands and causes sicca symptoms.
• Anti-Ro/SSA antibodies are an important diagnostic clue.
• Persistent gland enlargement should raise concern for lymphoma.
• Monitor for systemic autoimmune and lymphoproliferative complications.

Question 14. A 44-year-old woman has recurrent episodes of painful swelling of the knees and wrists. Radiographs show linear calcification within the cartilage of the knee. During an acute episode, synovial fluid contains rhomboid-shaped crystals that show weak positive birefringence under polarized light microscopy. Which of the following is the most likely diagnosis?

A. Gout
B. Calcium pyrophosphate deposition disease
C. Septic arthritis
D. Basic calcium phosphate deposition disease

Correct Answer: B. Calcium pyrophosphate deposition disease

Answer Explanation:
The presentation is characteristic of calcium pyrophosphate deposition disease. CPP crystals are typically rhomboid-shaped and demonstrate weak positive birefringence under polarized light microscopy. Chondrocalcinosis, representing calcification within cartilage or fibrocartilage, is a classic radiographic finding. CPPD can produce acute crystal arthritis that resembles gout or septic arthritis, and the knee and wrist are common sites. In an acutely inflamed joint, synovial fluid analysis is valuable because crystal identification does not completely eliminate the possibility of concurrent infection. Acute treatment can include NSAIDs, colchicine, systemic glucocorticoids, or intra-articular glucocorticoids depending on the patient’s clinical circumstances. Unlike gout, there is no established therapy that reliably removes CPP crystals from tissues.

Why the other options are incorrect:

Option A usually produces needle-shaped, strongly negatively birefringent monosodium urate crystals.

Option C can cause an acutely inflamed joint but does not explain characteristic CPP crystals and chondrocalcinosis.

Option D involves different calcium crystal types and does not produce classic chondrocalcinosis.

Study Guide:
• CPP crystals are rhomboid-shaped with weak positive birefringence.
• Chondrocalcinosis is a major radiographic clue.
• CPPD commonly affects knees and wrists.
• Acute attacks require anti-inflammatory treatment rather than urate-lowering therapy.

Question 15. A 63-year-old woman with rheumatoid arthritis has been taking methotrexate for 2 years with good disease control. She develops a persistent dry cough and progressive exertional dyspnea. Oxygen saturation is 91% while walking. Chest CT shows bilateral peripheral and basilar reticular abnormalities with areas of traction bronchiectasis. Which of the following is the most likely explanation?

A. Rheumatoid arthritis–associated interstitial lung disease
B. Acute bacterial bronchitis
C. Pulmonary embolism as the only diagnosis
D. Isolated methotrexate-induced hepatotoxicity

Correct Answer: A. Rheumatoid arthritis–associated interstitial lung disease

Answer Explanation:
This patient has features concerning for rheumatoid arthritis–associated interstitial lung disease, including chronic progressive dyspnea, dry cough, exertional desaturation, and CT evidence of fibrotic interstitial abnormalities with traction bronchiectasis. RA-associated ILD is an important extra-articular manifestation and can substantially affect morbidity and mortality. High-resolution CT and pulmonary function testing, including diffusion capacity, are important for characterizing disease and monitoring progression. A medication history remains essential because some drugs can contribute to pulmonary toxicity, but the chronic clinical course and characteristic fibrotic pattern support RA-associated ILD in this scenario. Management depends on severity, progression, radiographic pattern, and multidisciplinary assessment. Methotrexate-associated pneumonitis is generally an acute or subacute inflammatory presentation rather than this chronic fibrotic pattern.

Why the other options are incorrect:

Option B does not adequately explain persistent exertional desaturation and fibrotic CT abnormalities.

Option C could cause acute dyspnea but would not typically produce this chronic fibrotic imaging pattern.

Option D concerns liver toxicity and does not explain the pulmonary findings.

Study Guide:
• Rheumatoid arthritis can produce significant extra-articular lung disease.
• Chronic dry cough and exertional dyspnea warrant pulmonary evaluation.
• HRCT and pulmonary function testing help characterize and monitor ILD.
• Distinguish chronic RA-associated ILD from acute drug-induced pneumonitis.