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Oral Ulceration RA — SCE Rheumatology MCQ

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EasyRheumatoid ArthritisOral Ulceration RASCE Rheumatology

A 45-year-old woman with rheumatoid arthritis takes methotrexate 20 mg once weekly, folic acid and hydroxychloroquine. She develops painful mouth ulcers, a sore throat and spontaneous bruising. Her last full blood count was four months ago. Which is the most likely unifying explanation?

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Correct answer: C — Methotrexate toxicity with possible bone-marrow suppression

The correct answer is C. Oral ulceration and stomatitis are recognised manifestations of methotrexate toxicity. The accompanying sore throat and spontaneous bruising are warning features of leucopenia and thrombocytopenia from bone-marrow suppression rather than uncomplicated aphthous ulceration. Methotrexate should be withheld while an urgent full blood count and renal and liver function tests are obtained; weekly dosing, interacting medicines, infection and the folic-acid regimen should also be reviewed. Active rheumatoid arthritis does not ordinarily cause oral ulceration. Candidiasis more typically causes removable plaques or erythematous mucositis and does not explain bruising. Hydroxychloroquine is not a routine cause of isolated ulcerative stomatitis. Option A fails to account for the systemic haematological warning features.

Reference: Cipla EU Ltd. Methotrexate 2.5 mg Tablets, Summary of Product Characteristics, sections 4.4 and 4.8, updated 30 October 2024. https://www.medicines.org.uk/emc/product/9945/smpc