Inflammatory Myopathies — MCQs
Which of the following is not a feature of dermatomyositis?
A 60-year-old female presenting with proximal muscle weakness, increased serum creatine kinase levels, and no skin manifestations is likely to have:
Which of the following is not true about polymyositis
Which is NOT a feature of polymyositis?
A 40-year-old male presents with sudden, excruciating pain in his left great toe. The joint is swollen, red, and warm. What is the most likely cause?
A Thirty five year old female has proximal weakness of muscles, ptosis and easy fatigability. The most sensitive test to suggest the diagnosis is -
What is the most likely diagnosis for a young patient presenting with iritis and joint pain?
A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?
A 65-year-old man with history of back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in vertebrae. Diagnosis is -
In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?
Inflammatory Myopathies Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a feature of dermatomyositis?
- A. Salmon Patch (Correct Answer)
- B. Periungual telangiectasias
- C. Gottron's patch
- D. Mechanic's hands
Explanation: ***Salmon Patch*** - A **salmon patch** (also known as a nevus simplex or stork bite) is a common, benign vascular birthmark that presents as a flat, red or pink patch. - It is **not associated with dermatomyositis** and has no pathogenic link to the condition. *Gottron's patch* - **Gottron's patches** are a classic cutaneous manifestation of dermatomyositis, characterized by erythematous, violaceous, or dusky red papules or plaques over the **extensor surfaces of the metacarpophalangeal and interphalangeal joints**. - Their presence is highly suggestive of dermatomyositis, often preceding or co-occurring with muscle weakness. *Periungual telangiectasias* - **Periungual telangiectasias** are dilated capillaries around the nail folds and are a common skin manifestation of dermatomyositis. - They represent small vessel vasculopathy, a histological feature, and suggest microvascular damage often seen in systemic connective tissue diseases like dermatomyositis. *Mechanic's hands* - **Mechanic's hands** are a cutaneous feature seen in dermatomyositis (and other inflammatory myopathies like antisynthetase syndrome). - They are characterized by **hyperkeratosis**, fissuring, and scaling of the skin, particularly on the lateral and palmar aspects of the fingers, resembling the hands of a manual laborer.
Question 2: A 60-year-old female presenting with proximal muscle weakness, increased serum creatine kinase levels, and no skin manifestations is likely to have:
- A. Polymyositis (Correct Answer)
- B. Dermatomyositis
- C. Limb-girdle muscular dystrophy
- D. Inclusion body myositis
Explanation: ***Polymyositis*** - **Polymyositis** primarily affects adults, causing **proximal muscle weakness** (shoulders, hips, thighs) and elevated **creatine kinase (CK)** levels due to muscle damage [1]. - The absence of **skin manifestations** in this case strongly supports polymyositis over dermatomyositis, as dermatomyositis typically presents with characteristic cutaneous features [1]. *Dermatomyositis* - While dermatomyositis can present with identical **proximal muscle weakness** and elevated CK levels, it is characteristically associated with **skin manifestations** [1]. - The absence of **heliotrope rash**, **Gottron papules**, or **shawl sign** in this clinical scenario makes dermatomyositis less likely despite similar muscle involvement [1]. *Limb-girdle muscular dystrophy* - **Limb-girdle muscular dystrophy** is a genetically heterogeneous group of disorders, typically presenting in **childhood or adolescence**, though some forms can manifest later in life. - It causes **progressive symmetric muscle weakness** predominantly affecting the **shoulders and hips**, with highly variable CK levels depending on the specific genetic mutation. *Inclusion body myositis* - **Inclusion body myositis** typically affects older individuals (over 50), presenting with **progressive, asymmetrical muscle weakness**, more prominently in the **distal muscles** (e.g., forearm flexors, quadriceps). - While CK levels can be elevated, they are usually **less markedly increased** than in polymyositis or dermatomyositis, and the disease often progresses more slowly.
Question 3: Which of the following is not true about polymyositis
- A. Limb girdle weakness
- B. Para-neoplastic syndrome
- C. Ophthalmoplegia (Correct Answer)
- D. Spontaneous discharge in EMG
Explanation: ***Ophthalmoplegia*** - **Polymyositis** primarily affects **proximal limb and trunk muscles**, sparing the extraocular muscles [1]. - **Ophthalmoplegia**, or paralysis of the extraocular muscles, is not a typical feature of polymyositis and would suggest a different neuromuscular disorder. *Limb girdle weakness* - **Polymyositis** characteristically causes **symmetric proximal muscle weakness**, affecting the muscles of the shoulder (pectoral) and hip (pelvic) girdles [1]. - Patients typically present with difficulty rising from a chair, climbing stairs, or lifting objects overhead [1]. *Para-neoplastic syndrome* - Polymyositis, like other inflammatory myopathies, can be a **paraneoplastic syndrome**, particularly in older adults [2]. - It is important to screen for underlying malignancies in patients diagnosed with polymyositis, especially if they have atypical features or are above a certain age [2]. *Spontaneous discharge in EMG* - **Electromyography (EMG)** in polymyositis typically shows findings of muscle irritation and degeneration, including **spontaneous activity** (e.g., fibrillations, positive sharp waves) at rest. - These findings reflect active muscle inflammation and necrosis, which are hallmarks of the disease.
Question 4: Which is NOT a feature of polymyositis?
- A. Proximal muscle weakness
- B. Elevated serum creatine kinase (CK) levels
- C. Ocular muscle involvement (Correct Answer)
- D. Endomysial inflammation on muscle biopsy
Explanation: ***Ocular muscle involvement*** - **Polymyositis** primarily affects **proximal skeletal muscles**, sparing the **ocular** and facial muscles. - Involvement of **ocular muscles** is more characteristic of other neuromuscular disorders, such as **myasthenia gravis**. *Proximal muscle weakness* - This is a hallmark symptom of **polymyositis**, manifesting as difficulty with activities like rising from a chair or lifting objects [1]. - The weakness is typically **symmetric** and progressive, affecting muscles of the **shoulders, hips, and neck** [1]. *Elevated serum creatine kinase (CK) levels* - Elevated **CK levels** are a key laboratory finding in polymyositis, indicating **muscle damage** and inflammation. - The degree of **CK elevation** often correlates with disease activity and muscle breakdown. *Endomysial inflammation on muscle biopsy* - A **muscle biopsy** is crucial for diagnosing polymyositis, revealing characteristic **inflammatory infiltrates** consisting mainly of **CD8+ T cells** surrounding and invading non-necrotic muscle fibers. - This **endomysial inflammation** differentiates polymyositis from other myopathies.
Question 5: A 40-year-old male presents with sudden, excruciating pain in his left great toe. The joint is swollen, red, and warm. What is the most likely cause?
- A. Osteoarthritis
- B. Gout (Correct Answer)
- C. Septic arthritis
- D. Rheumatoid arthritis
Explanation: ***Gout*** - **Sudden onset** of **excruciating pain** in the **great toe** (podagra) with associated **swelling**, **redness**, and **warmth** is highly characteristic of acute gout [1]. - Gout is caused by the deposition of **monosodium urate crystals** in joints, leading to an inflammatory response [2]. *Osteoarthritis* - Characterized by **chronic, progressive joint pain** that worsens with activity and improves with rest, rather than sudden, excruciating pain. - Typically affects weight-bearing joints and **lacks the acute inflammatory signs** (redness, warmth) seen in gout [3]. *Septic arthritis* - Presents with acute joint pain, swelling, and warmth, similar to gout, but is usually accompanied by **systemic signs of infection** such as fever and chills. - Would require aspiration and culture of synovial fluid to differentiate, but the classic great toe involvement points away from this diagnosis initially. *Rheumatoid arthritis* - Presents as a **chronic, symmetrical polyarthritis**, primarily affecting small joints of the hands and feet. - While it causes inflammation, the **sudden, monoarticular** presentation in the great toe described here is not typical for rheumatoid arthritis [3].
Question 6: A Thirty five year old female has proximal weakness of muscles, ptosis and easy fatigability. The most sensitive test to suggest the diagnosis is -
- A. CPK levels
- B. Single fiber EMG (Correct Answer)
- C. Muscle Biopsy
- D. Edrophonium test
Explanation: ***Single fiber EMG*** - This patient's symptoms (proximal muscle weakness, ptosis, and easy fatigability) are highly suggestive of **myasthenia gravis**. - **Single fiber EMG (SFEMG)** is the **most sensitive electrophysiological test** for detecting impaired neuromuscular transmission in myasthenia gravis, even in cases with normal routine EMG [1]. *CPK levels* - **Creatine phosphokinase (CPK)** levels are typically elevated in muscle diseases involving **muscle fiber damage**, such as inflammatory myopathies (e.g., polymyositis, dermatomyositis) or muscular dystrophies [1]. - In myasthenia gravis, CPK levels are usually **within normal limits** as it is a disorder of the neuromuscular junction, not muscle fiber integrity. *Muscle Biopsy* - Muscle biopsy is performed to identify **structural abnormalities** of muscle tissue, inflammation, or fiber type changes, often used in diagnosing myopathies. - It is **not the primary diagnostic test** for myasthenia gravis, as there are no specific or consistent pathological changes evident upon muscle biopsy in this condition. *Edrophonium test* - The **Edrophonium (Tensilon) test** involves administering a short-acting acetylcholinesterase inhibitor, leading to a temporary improvement in muscle strength in myasthenia gravis. - While it was historically used for diagnosis, it is **less sensitive** than SFEMG and can have false positives or negatives, thus it is not considered the **most sensitive test** overall.
Question 7: What is the most likely diagnosis for a young patient presenting with iritis and joint pain?
- A. Gout
- B. RA
- C. AS (Correct Answer)
- D. Toxoplasma
Explanation: ***AS (Ankylosing Spondylitis)*** - **Iritis** (anterior uveitis) is a common extra-articular manifestation of **ankylosing spondylitis**, affecting up to 40% of patients [1]. - **Joint pain**, particularly in the axial skeleton (spine and sacroiliac joints), is a hallmark feature in young patients with AS [1]. *Gout* - Characterized by **recurrent attacks of acute inflammatory arthritis** due to **monosodium urate crystal deposition**. - While it causes severe joint pain, **iritis is not a typical manifestation** of gout. *RA (Rheumatoid Arthritis)* - RA is a **chronic autoimmune inflammatory disease** primarily affecting the **synovial joints** symmetrically, mostly in older adults. - While ocular manifestations like **scleritis** or **episcleritis** can occur, **iritis is less common** compared to AS. *Toxoplasma* - **Toxoplasmosis** primarily causes **chorioretinitis** (inflammation of the choroid and retina), not typically isolated iritis. - Although it can cause **arthralgia** (joint pain), it does not cause inflammatory arthritis like the spondyloarthropathies.
Question 8: A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?
- A. Marrow fibrosis
- B. Decreased chest wall expansion (Correct Answer)
- C. Pleural nodules
- D. Distal phalangeal joint involvement
Explanation: Decreased chest wall expansion - The patient's symptoms of morning back pain relieved by activity and warm baths are classic for ankylosing spondylitis. This condition commonly leads to fusion of the costovertebral joints, limiting chest wall expansion [1]. - Reduced chest wall expansion is a specific finding in ankylosing spondylitis, reflecting the ankylosis of the axial skeleton and enthesitis at various sites, including rib attachments [1]. Marrow fibrosis - Myelofibrosis is a bone marrow disorder characterized by fibrosis, typically leading to symptoms like fatigue, splenomegaly, and cytopenias, and is not directly associated with ankylosing spondylitis. - While inflammatory conditions can rarely cause reactive changes in bone marrow, widespread fibrosis is not a hallmark or common feature of ankylosing spondylitis. Pleural nodules - Pleural nodules are more characteristic of conditions like rheumatoid arthritis (rheumatoid nodules) or various lung malignancies/infections. - Although lung involvement, such as apical pulmonary fibrosis, can occur in ankylosing spondylitis, discrete pleural nodules are not common. Distal phalangeal joint involvement - Involvement of the distal interphalangeal (DIP) joints is a hallmark feature of psoriatic arthritis [2]. - Ankylosing spondylitis primarily affects the axial skeleton (spine and sacroiliac joints) and large peripheral joints, with DIP joint involvement being very rare [2].
Question 9: A 65-year-old man with history of back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in vertebrae. Diagnosis is -
- A. Lumbar canal stenosis
- B. Degenerative osteoarthritis of spine
- C. Ankylosing hyperosteosis
- D. Ankylosing spondylitis (Correct Answer)
Explanation: ***Ankylosing spondylitis*** - The presence of **syndesmophytes** on X-ray, in conjunction with **back pain**, **stiffness**, and **restricted chest movements**, are hallmark features of ankylosing spondylitis [1]. Also a **raised ESR** is consistent. - This chronic inflammatory disease primarily affects the **axial skeleton**, leading to fusion of vertebrae and progressive stiffness [1]. *Lumbar canal stenosis* - This condition involves **narrowing of the spinal canal**, which typically causes **radicular pain**, neurogenic claudication, and weakness in the legs [2]. - It does not present with restricted chest movements or syndesmophytes, and a raised ESR is not a typical finding. *Degenerative osteoarthritis of spine* - Characterized by **bone spurs (osteophytes)** and **disc space narrowing** due to wear and tear, rather than syndesmophytes. - While it causes back pain and stiffness, it typically does not lead to significant restriction of chest movements or a markedly elevated ESR associated with systemic inflammation. *Ankylosing hyperosteosis* - Also known as **Diffuse Idiopathic Skeletal Hyperostosis (DISH)**, characterized by **flowing ossification along the anterior longitudinal ligament** primarily on the right side of the spine [2]. - While it can cause stiffness and back pain, it generally does not involve a significantly elevated ESR or cause the same degree of restricted chest movement as true ankylosing spondylitis.
Question 10: In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?
- A. Gout (Correct Answer)
- B. Ankylosing spondylitis
- C. Osteoarthritis
- D. Rheumatoid arthritis
Explanation: ***Gout*** - **Gout** is characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints, most often the **big toe** [1],[2]. - A history of **high uric acid levels** (hyperuricemia) is a primary risk factor, as it leads to the formation of **uric acid crystals** in the joint [1],[3]. *Ankylosing spondylitis* - This condition is a chronic inflammatory disease primarily affecting the **spine and sacroiliac joints**, causing stiffness and pain, especially in the morning. - It is not directly associated with **high uric acid levels** or generally presenting as an acute, single swollen joint attack. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease characterized by the breakdown of cartilage over time, leading to pain and stiffness, especially with activity. - While it can cause joint swelling, it is typically a gradual process, not an acute, intensely painful attack, and is not linked to **uric acid levels**. *Rheumatoid arthritis* - **Rheumatoid arthritis** is an autoimmune disease causing chronic inflammation, primarily affecting multiple small joints symmetrically. - It presents with prolonged morning stiffness and is not directly caused by **high uric acid levels**, nor is its typical presentation an acute monoarthritis.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free