Rheumatology and Immunology Practice Questions

Q: A middle-aged woman presents with long -standing complaints of dryness of eyes and mouth, requiring frequent use of artificial tears and water while swallowing food. She also reports generalized pruritus and intermittent pain with stiffness in multiple small joints of the hands, suggestive of inflammatory arthritis. There is no history of skin tightening, Raynaud phenomenon, oral ulcers, or photosensitive rash. Based on this clinical presentation, what is the most likely diagnosis?

Sjogren syndrome. ***Sjogren syndrome*** - The presentation of **keratoconjunctivitis sicca** (dry eyes) and **xerostomia** (dry mouth) constitutes the classic **sicca complex** seen in Sjogren syndrome. - The associated **inflammatory polyarthritis** involving small joints of the hands is a common extraglandular manifestation of this autoimmune condition. *Systemic lupus erythematosus* - While SLE can cause arthralgias and sicca-like symptoms, the absence of **photosensitivity**, **oral ulcers**, and **malar rash** makes it less likely. - Serological markers such as **anti-dsDNA** or **anti-Smith antibodies** would typically be expected, but the clinical picture here is more localized to sicca and joint symptoms. *Rheumatoid arthritis* - While this patient has arthritis, the prominent and long-standing **sicca symptoms** suggest an underlying autoimmune process specifically affecting exocrine glands. - Rheumatoid arthritis typically presents with **symmetrical erosive arthritis** and **morning stiffness** lasting >1 hour, without the primary sicca complaints. *Scleroderma* - The absence of **Raynaud phenomenon**, **sclerodactyly** (skin tightening), and **telangiectasia** makes Scleroderma or systemic sclerosis an unlikely diagnosis. - While scleroderma can involve joint pain, it is characterized more by vascular and fibrotic changes rather than the primary glandular destruction seen here.

Q: What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Increase in titre of anti-dsDNA. In Systemic Lupus Erythematosus (SLE), monitoring disease activity is crucial for managing flares. The correct answer is **Option A: Increase in titre of anti-dsDNA**. ### **Why Anti-dsDNA is the Correct Answer** Anti-dsDNA antibodies are highly specific for SLE and their levels correlate directly with disease activity. A rising titre often precedes a clinical flare, particularly **Lupus Nephritis** [1]. When these antibodies increase, they form immune complexes that activate the complement system, leading to a simultaneous **decrease in C3 and C4 levels** [1]. This "rising anti-dsDNA and falling complement" pattern is the classic laboratory hallmark of an SLE flare. ### **Why Other Options are Incorrect** * **B. Increase in titre of ANA:** ANA is the best screening test (high sensitivity) but is useless for monitoring flares [1]. Once positive, the titre does not reliably correlate with disease severity or activity. * **C. Increase in anti-Sm:** Anti-Smith antibodies are the most specific for SLE, but like ANA, their levels remain relatively constant and do not fluctuate with disease activity [1]. * **D. Elevation of ESR:** While ESR is often raised in SLE, it is a non-specific marker of inflammation. It can be elevated due to infections or other co-morbidities, making it less reliable than anti-dsDNA for confirming a lupus-specific flare [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **Most Sensitive Test:** ANA (95-98%) [1]. * **Most Specific Test:** Anti-Sm (followed by anti-dsDNA) [1]. * **Drug-Induced Lupus:** Anti-Histone antibodies are the marker of choice. * **Neonatal Lupus/Sjogren’s:** Associated with Anti-Ro (SS-A) and Anti-La (SS-B) [1]. * **Active Nephritis Profile:** ↑ Anti-dsDNA + ↓ Complement (C3, C4) [1].

Q: Which is NOT a feature of polymyositis?

Gottron's rash. **Explanation:** The correct answer is **Gottron’s rash** because it is a pathognomonic cutaneous feature of **Dermatomyositis**, not Polymyositis [1]. While both conditions share similar patterns of muscle involvement, Polymyositis (PM) is strictly an inflammatory myopathy without primary skin manifestations. **Analysis of Options:** * **Gottron's rash (Correct):** These are erythematous, scaly eruptions over the dorsal aspects of the MCP and IP joints [1], [2]. Along with the Heliotrope rash, it distinguishes Dermatomyositis from Polymyositis [2]. * **Proximal muscle involvement:** This is the hallmark of PM. Patients typically present with symmetrical weakness of the shoulder and pelvic girdles (e.g., difficulty climbing stairs or combing hair) [1]. * **Pharyngeal muscle involvement:** In severe cases of PM, the striated muscles of the upper esophagus and pharynx are involved, leading to dysphagia and an increased risk of aspiration pneumonia [1]. * **Pain in limbs:** While the primary symptom is weakness, approximately 25-50% of patients with PM report muscle tenderness or myalgia during the acute phase [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Immunopathology:** PM is mediated by **CD8+ T-cells** (endomysial inflammation), whereas Dermatomyositis is mediated by **CD4+ T-cells and B-cells** (perifascicular atrophy). * **Antibodies:** **Anti-Jo-1** is the most common myositis-specific antibody and is strongly associated with **Interstitial Lung Disease (ILD)** and "Mechanic's hands" [1]. * **Malignancy:** Both are associated with increased cancer risk, but the risk is significantly higher in Dermatomyositis [2]. * **Diagnosis:** Gold standard is a **Muscle Biopsy**; initial screening involves elevated **CPK levels** [2].

Q: Which among the following is true about Caplan's syndrome?

Pneumoconiosis with rheumatoid arthritis. **Explanation:** **Caplan’s Syndrome** (also known as Rheumatoid Pneumoconiosis) is a clinical entity characterized by the development of specific pulmonary nodules in patients with **Pneumoconiosis** (most commonly Coal Worker's Pneumoconiosis, but also Silicosis or Asbestosis) [1] who also have **Rheumatoid Arthritis (RA)** [2]. 1. **Why Option D is Correct:** The syndrome represents an exaggerated inflammatory response in the lungs. In patients with a rheumatoid diathesis, the inhalation of inorganic dust triggers the formation of multiple, well-defined "Caplan nodules" (0.5 to 5 cm in diameter). These nodules are histologically similar to subcutaneous rheumatoid nodules but occur within the lung parenchyma, typically on a background of mild pneumoconiosis [1]. 2. **Why Other Options are Incorrect:** * **Option A:** While pneumoconiosis (like Silicosis) can cause hilar lymphadenopathy (e.g., "egg-shell calcification"), this is a feature of the primary disease, not Caplan’s syndrome [1]. * **Option B:** Congestive cardiac failure is not a defining component of this syndrome, though chronic lung disease can eventually lead to Cor Pulmonale. * **Option C:** There is no specific association between Caplan’s syndrome and HIV. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Look for multiple, bilateral, peripheral "crop-like" nodules that may appear suddenly. * **Serology:** Patients are typically **Rheumatoid Factor (RF) positive**. * **Timing:** Pulmonary nodules can appear before, during, or after the onset of clinical arthritis [2]. * **Differential:** Must be distinguished from **Erasmus Syndrome**, which is the association of Silicosis with Systemic Sclerosis (Scleroderma).

Question 1

A middle-aged woman presents with long -standing complaints of dryness of eyes and mouth, requiring frequent use of artificial tears and water while swallowing food. She also reports generalized pruritus and intermittent pain with stiffness in multiple small joints of the hands, suggestive of inflammatory arthritis. There is no history of skin tightening, Raynaud phenomenon, oral ulcers, or photosensitive rash. Based on this clinical presentation, what is the most likely diagnosis?

Accepted Answer

Sjogren syndrome

Answer

Systemic lupus erythematosus

Answer

Rheumatoid arthritis

Answer

Scleroderma

Question 2

A 32-year-old woman presents 6 months after rhinoplasty with a saddle nose deformity. Biopsy shows granulomatous inflammation. What is the most appropriate immediate management?

Accepted Answer

Start oral corticosteroids and investigate for systemic disease

Answer

Immediate revision rhinoplasty with cartilage graft

Answer

Perform immediate debridement of necrotic tissue

Answer

Prescribe topical antibiotics and observe

Question 3

What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Increase in titre of anti-dsDNA

Answer

Increase in titre of ANA

Answer

Increase in anti-Sm

Answer

Elevation of ESR

Question 4

Which is NOT a feature of polymyositis?

Accepted Answer

Gottron's rash

Answer

Pharyngeal muscle involvement

Answer

Proximal muscle involvement

Answer

Pain in limbs

Question 5

Which among the following is true about Caplan's syndrome?

Accepted Answer

Pneumoconiosis with rheumatoid arthritis

Answer

Pneumoconiosis with lymphadenopathy

Answer

Pneumoconiosis with congestive cardiac failure

Answer

Pneumoconiosis with HIV

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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