A 52-year-old woman with a 15-year history of seropositive rheumatoid arthritis presents with fatigue, recurrent infections, and early satiety. Physical examination reveals splenomegaly (4 cm below costal margin) and multiple firm subcutaneous nodules over the forearms. Labs show hemoglobin 10.2 g/dL, WBC 2800/mm3 with absolute neutrophil count of 900/mm3, and platelet count 148,000/mm3. Rheumatoid factor is strongly positive at 128 IU/mL. Which of the following best explains this clinical picture?

• A Methotrexate-induced bone marrow suppression
• B T-large granular lymphocyte leukemia complicating RA
• C Secondary Sjogren syndrome with associated lymphoma
• D Felty syndrome ✓

Explanation

Felty syndrome is the triad of seropositive rheumatoid arthritis, splenomegaly, and neutropenia. It occurs in long-standing, severe seropositive RA. The marked neutropenia with recurrent infections and splenomegaly is classic. Methotrexate can cause cytopenias but would not explain splenomegaly. T-LGL leukemia can mimic Felty but the full triad with strongly positive RF and subcutaneous nodules points to Felty.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.