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RA Lymphadenopathy Differential — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRA Lymphadenopathy DifferentialSCE Rheumatology

A 48-year-old woman with rheumatoid arthritis has taken methotrexate 20 mg once weekly for 6 years. Her arthritis is clinically quiescent, but she has developed a firm, non-tender 2.5 cm axillary lymph node that has persisted for 6 weeks. There is no evident local infection. Which statement best describes the appropriate differential diagnosis and management?

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Correct answer: C — Consider reactive adenopathy, infection, methotrexate-associated lymphoproliferative disorder and other malignancy; arrange suspected cancer pathway assessment and tissue diagnosis.

The correct answer is C. Persistent, firm, unexplained lymphadenopathy in a patient with RA requires a broad differential: RA-related reactive hyperplasia, infection—including opportunistic or reactivated infection—methotrexate-associated lymphoproliferative disorder, de novo lymphoma and other malignancy. Low-dose methotrexate does not exclude lymphoma; some associated lymphoproliferative disorders regress after withdrawal, but regression alone should not replace appropriate specialist assessment. NICE recommends considering a suspected cancer pathway referral for unexplained lymphadenopathy, even without B symptoms, and excision biopsy is generally preferred when lymphoma is suspected. Therefore B and C provide false reassurance. D prematurely assumes a specific aetiology and omits tissue diagnosis, while E incorrectly denies the recognised association between low-dose methotrexate and lymphoproliferative disease.

Reference: NICE. Suspected cancer: recognition and referral (NG12), recommendations 1.10.6 and 1.10.8, 2015 (current guidance). https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer