Rheumatology and Immunology Practice Questions

Q: Which of the following is commonly seen in SLE?

↑ed ANA. ***↑ed ANA*** - A positive **Antinuclear Antibody (ANA)** test is present in over 95% of patients with **Systemic Lupus Erythematosus (SLE)**, making it a highly sensitive screening test [1]. - While not specific to SLE, an elevated ANA is a cornerstone of its diagnostic criteria and indicates the presence of autoantibodies. *Autoimmune hemolytic anaemia* - While **autoimmune hemolytic anemia** can occur in SLE, it is not as universally common as an elevated ANA; it represents one of many potential hematologic manifestations [1]. - It results from autoantibodies targeting red blood cells, leading to their destruction, but is seen in a subset of SLE patients, not nearly all. *Raynaud's phenomena* - **Raynaud's phenomenon** is frequently associated with SLE and other connective tissue diseases, but it is not specific and occurs in many conditions, including primary Raynaud's without underlying disease. - It involves episodic vasospasm of small arteries, typically in the fingers and toes, in response to cold or stress. *Anti-ds DNA* - **Anti-double-stranded DNA (anti-dsDNA)** antibodies are highly specific for SLE and are crucial for diagnosis and monitoring disease activity, especially in lupus nephritis. - However, they are present in about 50-70% of SLE patients, making them less common than a positive ANA [1]. *Joint deformity* - **Joint deformity** can occur in some SLE patients, typically seen as **Jaccoud's arthropathy**, which is a reducible, non-erosive deformity. - Unlike rheumatoid arthritis, erosive joint damage and permanent fixed deformities are rare in SLE, and this is not a universal feature.

Q: Kveim test (historical) is used for diagnosis of

None of the options. ***None of the options.*** - While the Kveim test was historically used to diagnose **sarcoidosis**, it is now obsolete. - The Kveim test involved injecting a sarcoid tissue extract and observing for a reaction, but it is no longer used due to concerns about **specificity**, **standardization**, and **transmission of infectious agents**. *Wegeners granulomatosis* - This condition is now known as **Granulomatosis with Polyangiitis (GPA)**. - Diagnosis relies on clinical features, imaging, **biopsy showing granulomatous inflammation and vasculitis**, and **antineutrophil cytoplasmic antibodies (ANCAs)**, particularly **c-ANCA**. *Graves disease* - This is an **autoimmune hyperthyroid condition** diagnosed by specific thyroid hormone levels (low TSH, high free T3/T4) [2]. - The presence of **TSH receptor antibodies (TRAb)** or thyroid-stimulating immunoglobulins (TSI) are key diagnostic markers. *Sarcoidosis* - The Kveim test was indeed historically associated with sarcoidosis, but it is **no longer a current diagnostic tool**. - Current diagnosis involves clinical presentation, **imaging (chest X-ray/CT)** showing bilateral hilar lymphadenopathy, and **biopsy** demonstrating non-caseating granulomas [1].

Q: Which of the following is NOT true about gout?

Not found in women after menopause. **_Not found in women after menopause_** - Gout is actually **more common in women after menopause** due to declining estrogen levels, which can impact uric acid excretion. [2] - **Hyperuricemia** can occur in postmenopausal women, increasing their risk of developing gout. [1] *Not common in renal disorders* - **Renal insufficiency** is a major cause of secondary hyperuricemia because impaired kidney function leads to decreased excretion of uric acid. [1], [3] - Therefore, gout is highly common in individuals with **renal disorders**, making this statement incorrect. [3] *Uncommon in teetotalers* - While alcohol consumption, particularly beer and spirits, is a significant risk factor for gout, it is **not uncommon in teetotalers**. - Other factors like **dietary purine intake**, genetics, and medical conditions can cause gout regardless of alcohol intake. [1] *Uncommon in vegetarians* - This statement is generally true; vegetarians typically have a **lower risk of gout** due to a diet lower in purine-rich animal products. [1] - However, certain plant-based foods, such as some vegetables, legumes, and mushrooms, contain moderate amounts of purines, but typically not enough to significantly increase risk compared to meat-eaters.

Q: A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?

Articular erosions on X-ray. ***Articular erosions on X-ray*** - Articular erosions are classic radiographic hallmarks of **rheumatoid arthritis (RA)**, indicating destructive changes to cartilage and bone [1]. - While both RA and **Systemic Lupus Erythematosus (SLE)** can cause polyarthritis, erosive disease is characteristic of RA and generally absent in SLE [1]. *Soft tissue swelling at the proximal interphalangeal joint* - **Soft tissue swelling** can occur in both RA and SLE due to inflammation, making it a non-specific finding for differentiation [2]. - Both conditions frequently affect the **proximal interphalangeal (PIP) joints**, causing swelling and tenderness [2]. *Elevated ESR* - An **elevated Erythrocyte Sedimentation Rate (ESR)** is a general marker of inflammation and can be high in both RA and SLE [3]. - It reflects ongoing disease activity but does not help to distinguish between these two specific autoimmune conditions. *Juxta articular osteoporosis on X-ray* - **Juxta-articular osteoporosis** can be seen in both RA due to regional bone loss from inflammation and in SLE, often as a side effect of corticosteroid use. - This finding is therefore not specific enough to definitively differentiate between RA and SLE.

Q: Which is not an autoimmune disease

Sickle cell disease. ***Sickle cell disease*** - This is a **genetic disorder** caused by a mutation in the **beta-hemoglobin gene**, leading to abnormal hemoglobin (hemoglobin S) and sickle-shaped red blood cells. - It is an **inherited blood disorder**, not an autoimmune condition where the immune system attacks the body's own tissues. *SLE (Systemic Lupus Erythematosus)* - SLE is a **chronic autoimmune connective tissue disease** that can affect multiple organ systems. - It is characterized by the production of **autoantibodies** against various self-antigens, such as anti-dsDNA and anti-Sm antibodies. *Grave's disease* - This is an **autoimmune disorder** that leads to **hyperthyroidism**. - It is caused by the production of **autoantibodies** (thyroid-stimulating immunoglobulins) that mimic TSH and stimulate the thyroid gland to produce excessive thyroid hormones. *Myasthenia Gravis* - Myasthenia Gravis is an **autoimmune neuromuscular disease** characterized by fluctuating muscle weakness. - It is caused by **autoantibodies** that block or destroy acetylcholine receptors at the neuromuscular junction, impairing nerve-to-muscle communication.

Q: Connective tissue disorder which is associated with gastroesophageal reflux is -

Scleroderma. ***Scleroderma*** - **Scleroderma** (systemic sclerosis) frequently involves the gastrointestinal tract due to **fibrosis and vascular damage**, leading to impaired esophageal motility and **gastroesophageal reflux (GERD)** [1]. - The **dysmotility** is caused by the replacement of smooth muscle with **collagen**, particularly in the lower two-thirds of the **esophagus** [1]. *Dermatomyositis* - While dermatomyositis can affect the pharyngeal and upper esophageal muscles, leading to **dysphagia**, it is less commonly and directly associated with **acid reflux** in the generalized digestive tract compared to scleroderma [1]. - It primarily causes **proximal muscle weakness** and characteristic **skin rashes**, rather than widespread visceral fibrosis leading to GERD. *SLE* - **Systemic lupus erythematosus (SLE)** can cause various gastrointestinal symptoms, including **dysphagia** or **abdominal pain**, but **GERD** is not a prominent or characteristic feature of its esophageal involvement. - Gastrointestinal involvement in SLE is often related to **vasculitis** or **serositis**, not the widespread smooth muscle fibrosis seen in scleroderma. *Behcet's syndrome* - **Behcet's syndrome** is characterized by recurrent oral and genital ulcers, uveitis, and skin lesions. - While it can manifest with gastrointestinal symptoms, these typically involve **ulcerations** throughout the GI tract, rather than primary esophageal dysmotility and **GERD**.

Q: In which of the following types of arthritis are erosions typically not seen?

Systemic lupus erythematosus (SLE). ***Systemic lupus erythematosus (SLE)*** * SLE arthritis is primarily characterized by **non-erosive** and **non-deforming polyarthritis**, meaning it typically does not cause permanent joint damage or bone erosions [2]. * Joint pain and swelling are common in SLE, but radiographic findings rarely show the destructive changes seen in other inflammatory arthropathies. *Psoriasis* * Psoriatic arthritis often causes **erosive changes** and new bone formation, leading to distinctive radiographic findings such as "pencil-in-cup" deformities [1]. * It is a seronegative spondyloarthropathy that can affect peripheral and axial joints, as well as entheses [1]. *Rheumatoid arthritis* * Rheumatoid arthritis is a classic example of an **erosive arthritis**, where chronic inflammation leads to the destruction of cartilage and subchondral bone [3]. * Radiographic evidence of **joint erosions** is a hallmark feature, particularly in the small joints of the hands and feet [3]. *Gout* * Gout is a crystal-induced arthritis that can cause **erosive changes**, particularly in chronic, untreated cases, often presenting as characteristic "punched-out" erosions with overhanging edges [4]. * These erosions are due to the inflammatory response to **urate crystal deposition** in and around the joints [4].

Q: Reactive arthritis is caused by:

C. trachomatis. ***C. trachomatis*** - ***Chlamydia trachomatis*** is one of the most common bacterial triggers of reactive arthritis (formerly Reiter syndrome) - ***Urogenital infections*** with C. trachomatis lead to a sterile immune-mediated inflammatory arthritis, typically affecting lower limb joints - The organism is not present in the joint itself; rather, it triggers a cross-reactive immune response causing aseptic synovitis *Staphylococcus* - Staphylococcus species cause septic arthritis, not reactive arthritis - In septic arthritis, bacteria are directly present in the joint space and can be cultured from synovial fluid - This requires urgent antibiotic therapy and joint drainage, unlike reactive arthritis *N. gonorrhoeae* - Neisseria gonorrhoeae causes disseminated gonococcal infection with septic arthritis - While it can cause post-infectious arthritis in rare cases, it more commonly causes direct joint infection - Joint fluid is typically purulent with organisms detectable on Gram stain or culture *H. influenzae* - Haemophilus influenzae causes septic arthritis, particularly in children and immunocompromised patients - This is a direct bacterial infection of the joint, not an immune-mediated reactive process - The incidence has decreased significantly since introduction of the Hib vaccine

Q: Anticentromere antibodies are most commonly associated with

CREST syndrome. ***CREST syndrome*** - **Anticentromere antibodies** are highly specific for **CREST syndrome**, a limited form of systemic sclerosis. [1] - CREST syndrome is an acronym for its characteristic features: **Calcinosis**, **Raynaud's phenomenon**, **Esophageal dysmotility**, **Sclerodactyly**, and **Telangiectasias**. [1] *Diffuse cutaneous systemic sclerosis* - This more severe form of systemic sclerosis is typically associated with **anti-Scl-70 (anti-topoisomerase I)** antibodies. - It involves widespread skin thickening and early, significant internal organ involvement. [1] *Polymyositis* - Polymyositis is an inflammatory myopathy primarily associated with antibodies like **anti-Jo-1** (aminoacyl-tRNA synthetase). [1] - It’s characterized by **proximal muscle weakness** and elevated muscle enzymes. [1] *Mixed connective tissue disease* - This overlap syndrome is defined by the presence of **high titers of anti-U1-RNP** antibodies. [1] - It features signs and symptoms overlapping with systemic lupus erythematosus, systemic sclerosis, and polymyositis. [1]

Q: A 60-year-old male presents with chronic arthritis. Which of the following is the most likely cause?

OA. Crystal-induced arthritis, such as gout or calcium pyrophosphate deposition disease (CPPD), can lead to chronic arthritis associated with progressive joint damage and functional limitations [1]. While acute presentations are common, such as 'pseudogout' involving the knee, the underlying pathophysiology involves the balance of crystal formation and tissue concentration within the joint [1]. Specific causes like metabolic diseases or previous trauma may also predispose individuals to early-onset osteoarthritis [2].

Question 1

Which of the following is commonly seen in SLE?

Accepted Answer

↑ed ANA

Answer

Autoimmune hemolytic anaemia

Answer

Raynaud's phenomena

Answer

Anti-ds DNA

Answer

Joint deformity

Question 2

Kveim test (historical) is used for diagnosis of

Accepted Answer

None of the options

Answer

Wegeners granulomatosis

Answer

Graves disease

Answer

Sarcoidosis

Question 3

Which of the following is NOT true about gout?

Accepted Answer

Not found in women after menopause

Answer

Not common in renal disorders

Answer

Uncommon in teetotalers

Answer

Uncommon in vegetarians

Question 4

A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?

Accepted Answer

Articular erosions on X-ray

Answer

Soft tissue swelling at the proximal interphalangeal joint

Answer

Elevated ESR

Answer

Juxta articular osteoporosis on X-ray

Question 5

Which is not an autoimmune disease

Accepted Answer

Sickle cell disease

Answer

SLE

Answer

Grave's disease

Answer

Myasthenia Gravis

Question 6

Connective tissue disorder which is associated with gastroesophageal reflux is -

Accepted Answer

Scleroderma

Answer

Dermatomyositis

Answer

SLE

Answer

Behcet's syndrome

Question 7

In which of the following types of arthritis are erosions typically not seen?

Accepted Answer

Systemic lupus erythematosus (SLE)

Answer

Rheumatoid arthritis

Answer

Psoriasis

Answer

Gout

Question 8

Reactive arthritis is caused by:

Accepted Answer

C. trachomatis

Answer

Staphylococcus

Answer

N. gonorrhoeae

Answer

H. influenzae

Question 9

Anticentromere antibodies are most commonly associated with

Accepted Answer

CREST syndrome

Answer

Diffuse cutaneous systemic sclerosis

Answer

Polymyositis

Answer

Mixed connective tissue disease

Question 10

A 60-year-old male presents with chronic arthritis. Which of the following is the most likely cause?

Accepted Answer

OA

Answer

TB

Answer

RA

Answer

Pyogenic infection in infancy

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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