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Rheumatoid arthritis and infection — SCE Rheumatology MCQ

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ModerateRheumatological PharmacologyRheumatoid arthritis and infectionSCE Rheumatology

A 64-year-old woman with rheumatoid arthritis takes methotrexate and adalimumab. She presents with fever, rigors and a swollen prosthetic knee. CRP is 186 mg/L and synovial fluid is turbid with a neutrophil predominance. Gram stain is pending. Her next adalimumab dose is due tomorrow. What is the most appropriate management?

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

Reveal the answer and explanation

Correct answer: B — Withhold adalimumab and treat as septic arthritis

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

Withhold adalimumab and treat as septic arthritis is best because acute hot prosthetic joint with systemic sepsis features should be managed as septic arthritis and biologic therapy withheld. A is less suitable because increasing methotrexate does not treat infection; B is less suitable because routine ultrasound is too slow for a septic prosthetic joint; C is less suitable because giving adalimumab during serious infection increases risk; E is less suitable because steroid injection before excluding infection may worsen sepsis. Clinical pearl: in an immunosuppressed patient, infection must be excluded before attributing a hot joint to flare.

Reference: BSR bDMARD safety guideline 2019; BSR hot swollen joint guideline