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Difficulty: HardPreventive Care and Screening

A 52-year-old woman comes to the clinic for a routine health maintenance evaluation. She has a history of severe seropositive rheumatoid arthritis, which is currently well-controlled on a regimen of methotrexate and infliximab. She has a 25 pack-year smoking history and currently smokes one pack of cigarettes daily.

Review of her preventive health records reveals the following:
- Colonoscopy at age 46: no polyps or mucosal abnormalities
- Screening mammography at age 51: Breast Imaging Reporting and Data System (BI-RADS) category 1 (negative)
- Cervical cytology with human papillomavirus (HPV) cotesting at age 51: negative
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: administered 2 years ago
- Inactivated influenza vaccine: administered 1 month ago

The patient has never received a pneumococcal, zoster, or measles-mumps-rubella (MMR) vaccine in adulthood, though her childhood records indicate she completed the primary pediatric series for all standard vaccines. Her body mass index is 26 kg/m².

Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

  1. Low-dose chest computed tomography (LDCT)Answer
  2. B
    Measles, mumps, and rubella (MMR) vaccine
  3. Recombinant zoster vaccine (RZV)Answer
  4. D
    Screening mammography
  5. 20-valent pneumococcal conjugate vaccine (PCV20)Answer

Answer

The correct interventions are low-dose chest computed tomography (LDCT), recombinant zoster vaccine (RZV), and 20-valent pneumococcal conjugate vaccine (PCV20).
The correct answers represent the intersection of age-based guidelines and disease-specific risk factors. Low-dose chest computed tomography (LDCT) is indicated because the patient is over 50 years old with a 25 pack-year smoking history and is a current smoker, matching the USPSTF Grade B recommendation. Recombinant zoster vaccine (RZV) and 20-valent pneumococcal conjugate vaccine (PCV20) are indicated because she is receiving highly immunosuppressive therapy (infliximab and methotrexate); the ACIP guidelines recommend both of these inactivated vaccines for adults ≥19\geq 19 years with immunocompromising conditions.

Step-by-Step Solution

1
Analyze the patient's demographic profile, medical history, and current medications.
The patient is a 52-year-old active smoker (25 pack-years) who is significantly immunocompromised due to treatment with methotrexate and infliximab for rheumatoid arthritis.
Preventive care guidelines for cancer screening and immunizations are strictly based on age, specific risk factors (like smoking), and immune status.
2
Evaluate indications for cancer screening based on her age and smoking history.
Low-dose chest computed tomography (LDCT) is indicated. Mammography and cervical cancer screenings are currently up to date.
USPSTF recommends annual LDCT for adults aged 50-80 with a ≥20\geq 20 pack-year history who currently smoke. She had a mammogram at age 51 (biennial screening is recommended), so she is not due today.
3
Evaluate indications and contraindications for adult immunizations based on her age and immunosuppressed state.
Recombinant zoster vaccine (RZV) and 20-valent pneumococcal conjugate vaccine (PCV20) are indicated. MMR vaccine is contraindicated.
ACIP recommends RZV and pneumococcal vaccination for adults ≥19\geq 19 years who are immunocompromised. Live attenuated vaccines (MMR) are absolutely contraindicated in patients receiving TNF-alpha inhibitors like infliximab.

Key Concept

Preventive Care and Screening for Immunocompromised Adults
Estimated Time:2m 0s
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Topics

Preventive Care and Screening

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