1. A 68-year-old woman reports several days of new temporal headache, scalp tenderness, and jaw claudication, and this morning experienced a transient episode of monocular vision loss (amaurosis fugax). Inflammatory markers are markedly elevated. Which intervention is most appropriate now?
A) Schedule an outpatient temporal artery biopsy and begin low-dose prednisone 15 mg per day only after the biopsy result returns
B) Start an inhaled corticosteroid and arrange urgent ophthalmology follow-up
C) Initiate intravenous methylprednisolone pulse therapy immediately, before temporal artery biopsy, to prevent irreversible vision loss
D) Begin a topical ophthalmic corticosteroid to the affected eye
E) Withhold all glucocorticoids until biopsy confirms giant cell arteritis
ANSWER: C
Rationale:
This presentation is giant cell arteritis with visual involvement, an emergency in which delay risks permanent blindness from anterior ischemic optic neuropathy. The correct action is to start high-dose intravenous methylprednisolone pulse therapy immediately, before biopsy, because biopsy can still demonstrate vasculitis after glucocorticoids are begun and treatment must not wait. This makes Option C correct.
Option A: Option A is incorrect because deferring treatment for an outpatient biopsy, and using only low-dose prednisone, is inadequate and unsafe when vision is threatened.
Option B: Option B is incorrect because inhaled corticosteroids deliver airway-targeted drug and provide no meaningful systemic anti-inflammatory coverage for large-vessel vasculitis.
Option D: Option D is incorrect because topical ophthalmic corticosteroids do not treat the underlying systemic arteritis driving the ischemia.
Option E: Option E is incorrect because withholding glucocorticoids until biopsy confirmation forfeits the narrow window in which vision can be preserved.
2. A 60-year-old man with septic shock has received adequate fluid resuscitation but remains hypotensive on a norepinephrine infusion exceeding 0.25 micrograms per kilogram per minute, with escalating requirements. Which adjunctive pharmacological step is most appropriate?
A) Add low-dose hydrocortisone (approximately 200 mg per day by continuous infusion or in divided doses)
B) Begin high-dose dexamethasone as the preferred agent for shock reversal
C) Withhold any glucocorticoid until a short ACTH (adrenocorticotropic hormone) stimulation test identifies a responder
D) Stop vasopressors and rely on glucocorticoids alone to restore pressure
E) Give a single dose of inhaled corticosteroid
ANSWER: A
Rationale:
Current synthesis of the major septic shock trials supports adding low-dose hydrocortisone, about 200 mg per day, for shock that remains refractory after adequate fluid resuscitation and requires high, escalating vasopressor support. This patient meets that threshold, making Option A correct.
Option B: Option B is incorrect because hydrocortisone, not dexamethasone, is the agent used in septic shock; dexamethasone lacks the mineralocorticoid activity relevant here and its long duration complicates titration.
Option C: Option C is incorrect because the short ACTH stimulation test was found not to identify a benefiting subgroup and is not used to select patients for hydrocortisone.
Option D: Option D is incorrect because glucocorticoids are an adjunct and do not replace vasopressor support.
Option E: Option E is incorrect because an inhaled corticosteroid has no role in the systemic management of septic shock.
3. On postoperative day 1 after major abdominal surgery, a patient on chronic prednisone 20 mg per day becomes hypotensive despite aggressive fluids and escalating vasopressors. Laboratory studies show hyponatremia with a normal potassium, and the hemodynamic instability is out of proportion to estimated blood loss. What is the most appropriate immediate action?
A) Continue fluids and vasopressors alone, since steroid coverage is rarely needed postoperatively
B) Withhold glucocorticoids and wait for a random cortisol result before treating
C) Administer high-dose dexamethasone as first-line therapy for the suspected crisis
D) Start fludrocortisone to correct the hyponatremia
E) Give empiric intravenous hydrocortisone 100 mg without waiting for cortisol testing, drawing a pre-dose random cortisol if it will not delay treatment
ANSWER: E
Rationale:
Refractory hypotension out of proportion to blood loss, with hyponatremia and a normal potassium in a patient on chronic glucocorticoids, is the classic picture of perioperative adrenal crisis from a suppressed HPA (hypothalamic-pituitary-adrenal) axis; the preserved mineralocorticoid axis explains the absent hyperkalemia. The correct action is empiric intravenous hydrocortisone 100 mg without awaiting cortisol testing, with a pre-dose random cortisol drawn only if it does not delay therapy. This makes Option E correct.
Option A: Option A is incorrect because continuing fluids and pressors alone ignores the specific, urgent need for glucocorticoid replacement.
Option B: Option B is incorrect because delaying treatment for laboratory results risks a fatal but preventable crisis.
Option C: Option C is incorrect because hydrocortisone, not dexamethasone, is the conventional agent for acute crisis coverage.
Option D: Option D is incorrect because fludrocortisone is an oral mineralocorticoid for chronic replacement and does not address the acute glucocorticoid-deficient crisis, which does not involve mineralocorticoid deficiency.
4. Two patients are hospitalized with COVID-19 (coronavirus disease 2019). Patient 1 requires high-flow supplemental oxygen; Patient 2 is comfortable on room air with normal oxygen saturation. Regarding adjunctive dexamethasone, which approach is best supported by the evidence?
A) Give dexamethasone to both patients, since hospitalization alone is the indication
B) Give dexamethasone to Patient 1 (requiring oxygen) but withhold it from Patient 2 (on room air), in whom benefit is absent and a trend toward harm exists
C) Give dexamethasone to Patient 2 only, to prevent progression before oxygen is needed
D) Withhold dexamethasone from both, since glucocorticoids have no role in COVID-19
E) Give dexamethasone to both but at a higher dose for the patient on room air
ANSWER: B
Rationale:
The mortality benefit of dexamethasone in COVID-19 was concentrated in patients requiring respiratory support, with the greatest benefit in those needing mechanical ventilation and a smaller benefit in those needing supplemental oxygen; patients not requiring oxygen showed no benefit and a non-significant trend toward harm. Dexamethasone is therefore appropriate for the oxygen-requiring patient and should be withheld from the patient on room air. This makes Option B correct.
Option A: Option A is incorrect because hospitalization alone is not the indication; the oxygen requirement defines benefit.
Option C: Option C is incorrect because treating the room-air patient exposes them to risk without demonstrated benefit.
Option D: Option D is incorrect because dexamethasone does have a clear role in hypoxemic COVID-19 requiring respiratory support.
Option E: Option E is incorrect because the room-air patient should not receive the drug at all, let alone at a higher dose.
5. A 45-year-old woman with newly diagnosed rheumatoid arthritis is started on methotrexate, but its disease-modifying effect will take roughly 8 to 12 weeks to develop, and she has active, painful synovitis now. Which glucocorticoid strategy is most appropriate as part of her initial regimen?
A) Begin high-dose dexamethasone indefinitely as monotherapy
B) Avoid glucocorticoids entirely and rely on as-needed NSAIDs alone until methotrexate works
C) Start a superpotent topical corticosteroid over the affected joints
D) Use low-dose prednisone as bridge therapy to control synovial inflammation while awaiting the onset of methotrexate, with a plan to taper as the disease-modifying agent takes effect
E) Start an inhaled corticosteroid to achieve systemic anti-inflammatory effect
ANSWER: D
Rationale:
In early rheumatoid arthritis, low-dose prednisone is used as bridge therapy to suppress synovial inflammation during the weeks before a conventional disease-modifying agent such as methotrexate reaches full effect, after which the steroid is tapered. This matches the clinical goal, making Option D correct.
Option A: Option A is incorrect because indefinite high-dose dexamethasone monotherapy is not the bridging approach and exposes the patient to excessive long-term toxicity.
Option B: Option B is incorrect because withholding glucocorticoids leaves active synovitis inadequately controlled during the methotrexate onset window, and NSAIDs alone do not provide equivalent control.
Option C: Option C is incorrect because a topical corticosteroid cannot treat polyarticular systemic synovitis.
Option E: Option E is incorrect because inhaled corticosteroids are airway-targeted and do not deliver the systemic anti-inflammatory effect needed for rheumatoid synovitis.
6. A kidney transplant recipient maintained on tacrolimus and low-dose prednisone is started on phenytoin after a new seizure. Several weeks later, allograft function begins to deteriorate. Which mechanism most likely explains this development, and what is the appropriate concern?
A) Phenytoin induces CYP3A4 (cytochrome P450 3A4), lowering levels of both the calcineurin inhibitor and the glucocorticoid and thereby raising the risk of acute rejection, prompting close monitoring of drug levels and graft function
B) Phenytoin inhibits CYP3A4, causing immunosuppressant toxicity that damages the graft
C) Phenytoin has no interaction with these agents, so the deterioration must be unrelated to drug metabolism
E) Phenytoin blocks renal excretion of tacrolimus, producing nephrotoxic accumulation
ANSWER: A
Rationale:
Phenytoin is a CYP3A4 inducer, and both tacrolimus (a calcineurin inhibitor) and the glucocorticoid are CYP3A4 substrates. Induction lowers their concentrations, and falling immunosuppression below the protective threshold permits alloreactive T cell activation and acute rejection, which fits the deteriorating graft function and warrants close monitoring of levels and graft function. This makes Option A correct.
Option B: Option B is incorrect because phenytoin induces rather than inhibits CYP3A4, so the problem is subtherapeutic levels, not toxicity.
Option C: Option C is incorrect because there is a well-defined induction interaction, so the timing of deterioration after phenytoin is consistent with cause and effect.
Option D: Option D is incorrect because phenytoin lowers glucocorticoid exposure rather than increasing receptor expression and intensifying immunosuppression.
Option E: Option E is incorrect because the interaction is metabolic induction, not blockade of renal excretion producing accumulation.
7. A 58-year-old man with a metastatic brain lesion has worsening headache and focal deficits, and imaging shows extensive peritumoral vasogenic edema. Which glucocorticoid is preferred, and what is the pharmacological basis?
A) Hydrocortisone, because its mineralocorticoid activity supports cerebral perfusion pressure
B) Fludrocortisone, because mineralocorticoid effects reduce vasogenic edema
C) Dexamethasone, because its high potency, negligible mineralocorticoid activity that avoids worsening fluid retention, and long duration of action suit the setting, while it also reduces VEGF (vascular endothelial growth factor)-driven vascular permeability that fuels the edema
D) An inhaled corticosteroid, to minimize systemic exposure during treatment
E) A superpotent topical corticosteroid applied to the scalp over the lesion
ANSWER: C
Rationale:
Dexamethasone is the preferred agent for peritumoral vasogenic edema. Its high glucocorticoid potency, negligible mineralocorticoid activity (avoiding added sodium and water retention in a patient at risk of raised intracranial pressure), and long duration of action make it well suited, and mechanistically it reduces VEGF-driven vascular hyperpermeability that drives the edema. This makes Option C correct.
Option A: Option A is incorrect because hydrocortisone's mineralocorticoid activity is undesirable here and is not the basis for managing cerebral edema.
Option B: Option B is incorrect because fludrocortisone is a mineralocorticoid that would promote fluid retention rather than reduce edema.
Option D: Option D is incorrect because inhaled corticosteroids are airway-targeted and do not treat cerebral edema.
Option E: Option E is incorrect because a topical scalp corticosteroid cannot reach or treat intracranial peritumoral edema.
8. A 29-year-old woman with systemic lupus erythematosus (SLE) presents with a severe lupus nephritis flare: rising creatinine, heavy proteinuria, and active urinary sediment. Which approach to glucocorticoid therapy is most appropriate?
A) A short course of low-dose oral prednisone alone, tapered over a week
B) High-dose intravenous methylprednisolone pulse therapy followed by high-dose oral prednisone with a gradual taper, combined with a steroid-sparing immunosuppressant such as mycophenolate mofetil or cyclophosphamide for sustained organ-preserving control
C) Hydroxychloroquine dose optimization alone, without systemic glucocorticoids
D) An inhaled corticosteroid to limit systemic exposure
E) A superpotent topical corticosteroid for any associated rash, with no systemic therapy
ANSWER: B
Rationale:
Severe organ-threatening lupus, such as lupus nephritis, warrants high-dose intravenous methylprednisolone pulse therapy followed by high-dose oral prednisone with a gradual taper, combined with a longer-acting immunosuppressant such as mycophenolate mofetil or cyclophosphamide that provides sustained disease control and allows the steroid to be tapered. This makes Option B correct.
Option A: Option A is incorrect because low-dose prednisone alone is inadequate for severe nephritis, which requires high-dose induction and adjunctive immunosuppression.
Option C: Option C is incorrect because hydroxychloroquine optimization suits mild mucocutaneous or musculoskeletal flares, not active severe nephritis.
Option D: Option D is incorrect because inhaled corticosteroids are airway-targeted and do not treat lupus nephritis.
Option E: Option E is incorrect because a topical agent addresses only skin disease and leaves the organ-threatening renal flare untreated.
9. A 52-year-old woman with severe asthma has been maintained on high-dose inhaled fluticasone propionate (greater than 500 micrograms per day) for over a year. Routine ophthalmologic examination reveals new posterior subcapsular cataracts, and morning cortisol is low. How should this finding be interpreted and managed?
A) The cataracts cannot be related to inhaled therapy, because inhaled corticosteroids never reach the systemic circulation
B) The findings indicate she swallowed the medication rather than inhaling it, and technique correction alone will reverse the cataracts
C) The cataracts reflect untreated asthma rather than any drug effect
D) The morning cortisol is irrelevant, since inhaled corticosteroids cannot affect the HPA (hypothalamic-pituitary-adrenal) axis
E) These are recognized systemic effects of high-dose inhaled corticosteroids, reflecting the systemically available inhaled fraction, and management is to use the lowest effective dose with regular review
ANSWER: E
Rationale:
At high doses, the inhaled fraction of an inhaled corticosteroid that reaches the systemic circulation is large enough to cause measurable systemic effects, including HPA axis suppression, posterior subcapsular cataracts, and skin thinning. The low morning cortisol and new cataracts in a patient on high-dose fluticasone are consistent with this, and the appropriate response is to use the lowest effective dose with regular review. This makes Option E correct.
Option A: Option A is incorrect because the inhaled fraction does reach the systemic circulation and is not removed by first-pass metabolism, so systemic effects are possible.
Option B: Option B is incorrect because the systemic effects arise mainly from the inhaled fraction, not from swallowed drug, and technique correction will not reverse established cataracts.
Option C: Option C is incorrect because posterior subcapsular cataracts in this context are a recognized drug effect rather than a consequence of asthma itself.
Option D: Option D is incorrect because high-dose inhaled corticosteroids can suppress the HPA axis, so the low cortisol is relevant.
10. A patient who has taken prednisone 25 mg per day for the past 2 months for an inflammatory condition is scheduled for a major elective abdominal operation under general anesthesia. Which perioperative glucocorticoid plan is most appropriate?
A) No supplementation beyond the usual oral dose, since chronic steroid users tolerate surgery without coverage
B) A single 50 mg dose of hydrocortisone at induction with no further dosing
C) Withhold the chronic prednisone on the morning of surgery to reduce infection risk
D) Provide full stress-dose coverage with intravenous hydrocortisone 100 mg at induction followed by 50 mg every 8 hours for the first 24 hours, then taper over 48 to 72 hours back to the chronic dose, because the dose-duration threshold predicts substantial HPA (hypothalamic-pituitary-adrenal) axis suppression
E) Substitute an inhaled corticosteroid perioperatively to maintain coverage
ANSWER: D
Rationale:
A patient on more than 20 mg of prednisone per day for more than 3 weeks is presumed to have substantial HPA axis suppression and should receive full stress-dose coverage for a major procedure: intravenous hydrocortisone 100 mg at induction, then 50 mg every 8 hours for the first 24 hours, with a taper over 48 to 72 hours back to the chronic dose. This matches the dose-duration risk framework, making Option D correct.
Option A: Option A is incorrect because this high-dose, long-duration user requires supplementation; omitting it risks adrenal crisis.
Option B: Option B is incorrect because a single low dose with no further coverage is inadequate for a major procedure in a suppressed patient.
Option C: Option C is incorrect because withholding the chronic steroid removes baseline coverage and increases crisis risk rather than reducing infection meaningfully.
Option E: Option E is incorrect because an inhaled corticosteroid cannot provide reliable systemic perioperative stress coverage.
11. A previously healthy adult presents to the emergency department with fever, neck stiffness, and altered mental status, and bacterial meningitis is strongly suspected. The team is preparing both empiric antibiotics and adjunctive dexamethasone. Regarding the timing of dexamethasone, which instruction is correct?
A) Give dexamethasone only after 48 hours of antibiotic therapy if the patient has not improved
B) Give dexamethasone several days later, once cerebrospinal fluid cultures have returned
C) Give dexamethasone with or immediately before the first antibiotic dose, because suppressing the inflammatory surge that follows antibiotic-induced bacterial lysis is what reduces severe neurological sequelae
D) Withhold dexamethasone entirely, since glucocorticoids are contraindicated in central nervous system infection
E) Give dexamethasone only after the inflammatory response has fully resolved
ANSWER: C
Rationale:
Adjunctive dexamethasone reduces severe neurological sequelae, such as sensorineural hearing loss, by blunting the intense subarachnoid inflammatory response triggered when antibiotics lyse bacteria. The benefit depends on the drug being present with or immediately before the first antibiotic dose, making Option C correct.
Option A: Option A is incorrect because waiting 48 hours misses the inflammatory surge that accompanies initial bacterial killing.
Option B: Option B is incorrect because delaying until cultures return forfeits the critical timing window.
Option D: Option D is incorrect because adjunctive dexamethasone is beneficial in bacterial meningitis rather than contraindicated.
Option E: Option E is incorrect because giving it after inflammation has resolved provides no protection against the early lysis-driven injury.
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