Large Vision-Language Models (LVLMs) augmented with Retrieval-Augmented Generation (RAG) are increasingly employed in medical AI to enhance factual grounding through external clinical image-text retrieval. However, this reliance creates a significant attack surface. We propose MedThreatRAG, a novel multimodal poisoning framework that systematically probes vulnerabilities in medical RAG systems by injecting adversarial image-text pairs. A key innovation of our approach is the construction of a simulated semi-open attack environment, mimicking real-world medical systems that permit periodic knowledge base updates via user or pipeline contributions. Within this setting, we introduce and emphasize Cross-Modal Conflict Injection (CMCI), which embeds subtle semantic contradictions between medical images and their paired reports. These mismatches degrade retrieval and generation by disrupting cross-modal alignment while remaining sufficiently plausible to evade conventional filters. While basic textual and visual attacks are included for completeness, CMCI demonstrates the most severe degradation. Evaluations on IU-Xray and MIMIC-CXR QA tasks show that MedThreatRAG reduces answer F1 scores by up to 27.66% and lowers LLaVA-Med-1.5 F1 rates to as low as 51.36%. Our findings expose fundamental security gaps in clinical RAG systems and highlight the urgent need for threat-aware design and robust multimodal consistency checks. Finally, we conclude with a concise set of guidelines to inform the safe development of future multimodal medical RAG systems.

Retrieval-Augmented Generation (RAG) has emerged as a powerful approach to boost the capabilities of large language models (LLMs) by incorporating external, up-to-date knowledge sources. However, this introduces a potential vulnerability to knowledge poisoning attacks, where attackers can compromise the knowledge source to mislead the generation model. One such attack is the PoisonedRAG in which the injected adversarial texts steer the model to generate an attacker-chosen response to a target question. In this work, we propose novel defense methods, FilterRAG and ML-FilterRAG, to mitigate the PoisonedRAG attack. First, we propose a new property to uncover distinct properties to differentiate between adversarial and clean texts in the knowledge data source. Next, we employ this property to filter out adversarial texts from clean ones in the design of our proposed approaches. Evaluation of these methods using benchmark datasets demonstrate their effectiveness, with performances close to those of the original RAG systems.