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Methotrexate pneumonitis — SCE Rheumatology MCQ

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HardRheumatological PharmacologyMethotrexate pneumonitisSCE Rheumatology

A patient has MPO-ANCA-positive pulmonary haemorrhage with hypoxaemia and biopsy-proven crescentic pauci-immune glomerulonephritis. What is the appropriate remission-induction principle?

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Correct answer: A — Rituximab- or cyclophosphamide-based induction with selective plasma exchange

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

B is correct. Diffuse alveolar haemorrhage and crescentic glomerulonephritis are organ-threatening AAV requiring immediate rituximab- or cyclophosphamide-based induction with glucocorticoids. Plasma exchange is considered selectively in severe renal disease or hypoxaemic pulmonary haemorrhage, but it does not replace immunosuppression. A mistakes ANCA subtype for severity. C omits disease control. D waits for irreversible injury. E uses an ineffective AAV strategy. Infection sampling, renal trajectory, haemorrhage severity and anti-GBM testing refine the induction plan.

Reference: 2025 BSR management recommendations for ANCA-associated vasculitis: https://academic.oup.com/rheumatology/article/64/8/4470/8160140