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MTX Lung Investigation — SCE Rheumatology MCQ

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HardRheumatology PharmacologyMTX Lung InvestigationSCE Rheumatology

Six weeks after methotrexate was increased to 20 mg weekly, a patient with rheumatoid arthritis develops fever, dry cough, exertional hypoxaemia and bilateral ground-glass change. Neutrophils are normal and she is haemodynamically stable. What is the best immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Withhold methotrexate and urgently assess for infection, drug pneumonitis and inflammatory lung disease

Explanation lettering: D = shown as B · E = shown as C · B = shown as D · C = shown as E

B is correct. New respiratory symptoms and hypoxaemia after methotrexate require the drug to be withheld while infection, drug pneumonitis and inflammatory lung disease are assessed urgently. A normal neutrophil count does not exclude opportunistic or routine infection. CT ground-glass change is not pathognomonic, so C overstates diagnostic certainty and antifibrotics are not the acute treatment. D under-reacts to clinically significant lung disease. E treats the wrong toxicity mechanism and specifies an unsafe restart criterion. If multidisciplinary assessment supports methotrexate pneumonitis, methotrexate is normally withdrawn permanently and glucocorticoids may be required; the immediate answer deliberately preserves diagnostic safety before that irreversible conclusion.

Reference: 2025 BSR guideline for prescription and monitoring of conventional synthetic DMARDs: https://academic.oup.com/rheumatology/article/65/2/keaf522/8322743