Rheumatology and Immunology Practice Questions

Q: Indications for use of cyclophosphamide in SLE are:

Diffuse proliferative glomerulonephritis. Diffuse proliferative glomerulonephritis - **Cyclophosphamide** is a potent immunosuppressant often used in severe manifestations of **systemic lupus erythematosus (SLE)**, particularly **lupus nephritis**. - **Diffuse proliferative glomerulonephritis (class IV lupus nephritis)** is a severe form of kidney involvement in SLE, characterized by significant inflammation and immune complex deposition, for which cyclophosphamide is a first-line treatment due to its ability to induce remission and prevent progression to end-stage renal disease. *Arthritis* - **Arthritis** in SLE is typically managed with less aggressive therapies such as **NSAIDs**, **hydroxychloroquine**, or low-dose **corticosteroids** [1]. - Cyclophosphamide is generally reserved for life-threatening or organ-threatening manifestations due to its significant side effects. *Oral ulcers* - **Oral ulcers** in SLE are usually a mild cutaneous manifestation and are managed with topical treatments, **hydroxychloroquine**, or occasionally low-dose **systemic corticosteroids**. - The use of cyclophosphamide for oral ulcers would be inappropriate given its toxicity profile. *Anti D NA antibody +ive patients* - While **anti-dsDNA antibodies** are characteristic of SLE and often correlate with disease activity, particularly **lupus nephritis**, their presence alone does not indicate the need for cyclophosphamide [2]. - The decision to use cyclophosphamide is based on the presence of severe organ-threatening disease, not solely on antibody positivity.

Q: All are features of seronegative spondyloarthropathies except -

RA factor positive. ***RA factor positive*** - Seronegative spondyloarthropathies are specifically defined by the **absence of rheumatoid factor (RF)** in the blood. - Therefore, a positive RA factor would exclude a diagnosis of seronegative spondyloarthropathy. *Uveitis* - **Uveitis**, particularly **anterior uveitis**, is a common extra-articular manifestation of several seronegative spondyloarthropathies, such as ankylosing spondylitis and reactive arthritis [1]. - Its presence is a characteristic feature, not an exclusion criterion. *Occur in young age* - Seronegative spondyloarthropathies, such as **ankylosing spondylitis** and **reactive arthritis**, typically present in younger individuals, often before the age of 40. - This is a distinguishing feature compared to other arthropathies that might manifest later in life. *HLA-B27 positive* - **HLA-B27 positivity** is a strong genetic association with many seronegative spondyloarthropathies, particularly ankylosing spondylitis and reactive arthritis [1]. - While not universally present in all cases, it is a hallmark feature that aids in diagnosis [2].

Q: Windswept deformity of the knee is seen in -

Rheumatoid arthritis. **Rheumatoid arthritis** - **Windswept deformity** (valgus deformity in one knee and varus deformity in the other) is a classic finding in advanced rheumatoid arthritis due to severe joint destruction and instability. - It results from progressive articular and periarticular destruction, especially affecting the **ligaments** and **cartilage**, leading to asymmetric changes in both knees. *Osteoarthritis* - While osteoarthritis can cause **varus** or **valgus deformities** in the knee, it is typically unilateral or causes similar deformities in both knees due to cartilage loss [1]. - It does not typically present with the characteristic **contralateral deformities** seen in a windswept knee [1]. *Ankylosing Spondylitis* - Primarily affects the **axial skeleton** (spine and sacroiliac joints), leading to stiffness and fusion. - Peripheral joint involvement, when present, usually affects large joints but does not typically manifest as a **windswept deformity** of the knees. *Psoriatic arthritis* - Can affect peripheral joints, sometimes causing **arthritis mutilans** or **dactylitis**. - While it can cause joint deformities, a specific **windswept deformity** of the knees is not a characteristic or common feature.

Q: Uveoparotitis is seen in

Sarcoidosis. ***Sarcoidosis*** - **Uveoparotitis** (inflammation of the uveal tract of the eye and the parotid glands) is a classic manifestation of **sarcoidosis**, particularly when associated with **facial nerve palsy (Heerfordt's syndrome)**. - Sarcoidosis is a multisystem granulomatous disease that can affect various organs, including the eyes, salivary glands, and lungs. *Sjogren's syndrome* - Characterized by **dry eyes** (keratoconjunctivitis sicca) and **dry mouth** (xerostomia) due to immune-mediated destruction of exocrine glands. - While it can involve the parotid glands, it typically causes chronic inflammation leading to dryness, not necessarily acute uveoparotitis. *Rheumatoid arthritis* - Primarily an inflammatory arthritis affecting **synovial joints**, leading to joint destruction and deformity. - Ocular involvement can include **scleritis** or **episcleritis**, but not typically uveitis or parotitis as a combined syndrome. *SLE* - A systemic autoimmune disease with diverse manifestations, including kidney disease, skin rashes, and arthritis. - Ocular manifestations can include **retinal vasculitis** or **conjunctivitis**, but uveitis and parotitis as a specific syndrome like uveoparotitis are not characteristic.

Q: Antinuclear-antibodies are present in what percentage of cases of SLE ?

More than 90%. ***More than 90%*** - **Antinuclear antibodies (ANAs)** are detected in over 90% of patients with **systemic lupus erythematosus (SLE)** [1]. - Due to their very high sensitivity, ANAs are a crucial **screening test** for SLE, and a negative ANA test makes the diagnosis of SLE highly unlikely [1]. *70%* - While ANA positivity is essential for SLE diagnosis, 70% is **too low** to reflect the true prevalence of ANAs in SLE patients [1]. - A sensitivity of 70% would mean a relatively high number of false negatives, which is not characteristic of ANA for SLE. *50%* - A 50% positivity rate is **significantly lower** than the established prevalence for ANAs in SLE, which is typically above 90% [1]. - Such a low percentage would make the ANA test a poor screening tool for SLE, which contradicts its clinical utility. *80%* - An 80% ANA positivity rate is still **lower than the generally accepted figure**, which is often cited as 95-98% in most cases of active SLE [1]. - While 80% is high, it doesn't quite capture the near-universal presence of ANAs in SLE, which is why it is used as an initial screening marker.

Q: All are seronegative spondyloarthritides with ocular manifestations, except

Rheumatoid arthritis. ***Rheumatoid arthritis*** - While rheumatoid arthritis can have **ocular manifestations** (e.g., **scleritis**, **keratoconjunctivitis sicca**) [1], it is categorized as a **seropositive** arthritis due to the presence of **rheumatoid factor** and **anti-CCP antibodies** in most cases. - The question specifically asks for a condition that is *not* a seronegative spondyloarthritide. *Psoriatic arthritis* - This is a **seronegative spondyloarthritide** and can present with various **ocular manifestations**, including **conjunctivitis** and **uveitis**. - It lacks **rheumatoid factor** and typically involves the skin and joints. *Ankylospondylitis* - This is a classic example of a **seronegative spondyloarthritide**, strongly associated with **HLA-B27** [2]. - **Acute anterior uveitis** is a common ocular complication, affecting up to 40% of patients [2]. *Reiter's disease* - Now more commonly referred to as **reactive arthritis**, it is a **seronegative spondyloarthritide** by definition. - Ocular manifestations are prominent and include **conjunctivitis** and **anterior uveitis**, often part of the classic triad (arthritis, urethritis, conjunctivitis) [2].

Q: Deposition of Anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen in:

SLE. ### SLE - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are involved in the pathophysiology of organ damage in this autoimmune disease [2]. - The deposition of these antibodies and immune complexes in various tissues like the **kidney (lupus nephritis)**, **skin (malar rash, discoid lupus)**, **choroid plexus (neuropsychiatric lupus)**, and **joints (arthralgia/arthritis)** is characteristic of SLE [1]. ### Good pasture - Goodpasture syndrome is characterized by **anti-glomerular basement membrane (anti-GBM) antibodies** that primarily target the **kidneys** and **lungs**. - It does not involve the deposition of anti-dsDNA antibodies or affect the skin, choroid plexus, or joints in the same manner as SLE. ### Raynauds disease - Raynaud's disease is a **vasospastic disorder** affecting small arteries, typically in the fingers and toes, leading to episodic color changes (white, blue, red). - It is not an autoimmune disease characterized by antibody deposition in organs, although it can be a symptom of underlying connective tissue diseases like SLE [1]. ### Scleroderma - Scleroderma (systemic sclerosis) is an autoimmune disease characterized by **fibrosis** of the skin and internal organs, and **vascular dysfunction**. - While it can involve **autoantibodies (e.g., anti-topoisomerase I, anti-centromere)**, it is not primarily associated with anti-dsDNA antibody deposition or the specific pattern of organ involvement seen in SLE [2].

Q: 45-year-old man presented to outpatient department with hot, swollen left big toe and a painful lesion on the rim of his left pinna. Polarized light microscopy of the synovial fluid shows dense neutrophilic infiltrate and crystals that are negatively birefringent. Patient is likely to be suffering from?

Gout. ***Gout*** - The presentation of a **hot, swollen left big toe** (podagra), a painful lesion on the **helix of the ear**, and **negatively birefringent crystals** in synovial fluid is classic for gout [1]. - These crystals are **monosodium urate**, formed from elevated uric acid levels, depositing in joints and soft tissues [1]. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton**, causing chronic back pain and stiffness that improves with exercise, and would not present with acute podagra or ear lesions. - While it can be associated with **HLA-B27**, its synovial fluid findings would not include negatively birefringent crystals. *Rheumatoid arthritis* - Characterized by **symmetric polyarthritis** primarily affecting small joints, morning stiffness lasting over 30 minutes, and typically involves positive **rheumatoid factor** and **anti-CCP antibodies**. - Synovial fluid in rheumatoid arthritis would show inflammatory changes but not the specific negatively birefringent crystals seen in gout [1]. *Seronegative arthritis* - This is a broad category including conditions like **psoriatic arthritis, reactive arthritis, and ankylosing spondylitis**, all of which lack **rheumatoid factor**. - None of these conditions typically present with **negatively birefringent crystals** in joint fluid or **tophi-like lesions** on the ear helix [1].

Q: Menisci calcification is seen with

Pseudogout. ***Pseudogout*** - **Pseudogout**, also known as calcium pyrophosphate deposition (CPPD) disease, characteristically involves the deposition of **calcium pyrophosphate crystals** in articular cartilage, leading to its calcification, including the menisci. - This calcification, visible on X-ray, is known as **chondrocalcinosis** and is a hallmark of pseudogout. *Hypothyroidism* - While hypothyroidism can cause various musculoskeletal symptoms, it is not typically associated with **meniscal calcification** or chondrocalcinosis. - It more commonly presents with **arthralgia**, myalgia, and effusions due to metabolic imbalances. *Gout* - **Gout** is caused by the deposition of **monosodium urate crystals** in joints, leading to inflammation and pain, often in the big toe. - It does not cause **meniscal calcification** or chondrocalcinosis; instead, it can cause erosions and tophi but not calcified cartilage. *Hyperparathyroidism* - **Hyperparathyroidism** causes increased bone turnover and **hypercalcemia**, which can lead to various bone and joint problems. - While it can be associated with soft tissue calcifications and is a risk factor for **CPPD** (pseudogout), directly causing menisci calcification is not its primary or characteristic feature.

Q: A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -

Temporal arteritis. ***Temporal arteritis*** - The combination of **unilateral headache**, **visual disturbances** (blindness), a **palpable temporal artery** (thick cord-like structure), and a **markedly elevated ESR** (80 mm/hr) in an elderly patient is highly suggestive of temporal arteritis (giant cell arteritis) [1]. - This condition is an **inflammatory vasculitis** that can lead to permanent vision loss if not promptly treated with corticosteroids [1]. *Migraine* - While migraines cause **unilateral headaches**, they typically present with **photophobia**, phonophobia, and aura, and are not associated with a palpable temporal artery or such a high ESR [1]. - Blindness is not a typical persistent symptom of migraine; visual disturbances are usually transient auras [3]. *Sinusitis* - Sinusitis causes **facial pain** and headache, often localized to the sinus regions, and may be accompanied by congestion and discharge. - It does not cause permanent blindness or present with a palpable temporal artery, nor does it typically result in an ESR of 80 mm/hr. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, retro-orbital location, and autonomic symptoms like **lacrimation** and **nasal congestion**, but they do not cause a palpable temporal artery, blindness, or an elevated ESR [2]. - The pain is usually episodic and short-lived, unlike the persistent symptoms described [2].

Question 1

Indications for use of cyclophosphamide in SLE are:

Accepted Answer

Diffuse proliferative glomerulonephritis

Answer

Arthritis

Answer

Oral ulcers

Answer

Anti D NA antibody +ive patients

Question 2

All are features of seronegative spondyloarthropathies except -

Accepted Answer

RA factor positive

Answer

Uveitis

Answer

Occur in young age

Answer

HLA-B27 positive

Question 3

Windswept deformity of the knee is seen in -

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Ankylosing Spondylitis

Answer

Psoriatic arthritis

Question 4

Uveoparotitis is seen in

Accepted Answer

Sarcoidosis

Answer

Sjogren's syndrome

Answer

Rheumatoid arthritis

Answer

SLE

Question 5

Antinuclear-antibodies are present in what percentage of cases of SLE ?

Accepted Answer

More than 90%

Answer

70%

Answer

50%

Answer

80%

Question 6

All are seronegative spondyloarthritides with ocular manifestations, except

Accepted Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Ankylospondylitis

Answer

Reiter's disease

Question 7

Deposition of Anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen in:

Accepted Answer

SLE

Answer

Good pasture

Answer

Raynauds disease

Answer

Scleroderma

Question 8

45-year-old man presented to outpatient department with hot, swollen left big toe and a painful lesion on the rim of his left pinna. Polarized light microscopy of the synovial fluid shows dense neutrophilic infiltrate and crystals that are negatively birefringent. Patient is likely to be suffering from?

Accepted Answer

Gout

Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

Seronegative arthritis

Question 9

Menisci calcification is seen with

Accepted Answer

Pseudogout

Answer

Hypothyroidism

Answer

Gout

Answer

Hyperparathyroidism

Question 10

A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -

Accepted Answer

Temporal arteritis

Answer

Migraine

Answer

Sinusitis

Answer

Cluster headache

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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