A 55-year-old man with seropositive rheumatoid arthritis (RF positive, anti-CCP positive) on methotrexate 20 mg/week and folic acid for 2 years presents with fatigue, recurrent infections, and splenomegaly (16 cm). CBC shows WBC 2.1 × 10⁹/L with absolute neutrophil count of 780/µL and normal hemoglobin and platelets. Which diagnosis best explains these findings?

• A Methotrexate-induced myelosuppression
• B T-cell large granular lymphocytic leukemia
• C Secondary Sjogren syndrome
• D Felty syndrome ✓

Explanation

Felty syndrome is the triad of seropositive RA, splenomegaly, and neutropenia. It occurs in long-standing, usually severe seropositive RA. The neutropenia results from peripheral destruction and splenic sequestration. MTX-induced myelosuppression typically causes pancytopenia, not isolated neutropenia with splenomegaly. T-LGL leukemia can mimic Felty syndrome but is diagnosed by flow cytometry showing clonal T-LGL expansion. Sjogren syndrome does not cause neutropenia with splenomegaly.

Reference: Kelley and Firestein's Textbook of Rheumatology, 11th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.