Rheumatology and Immunology Practice Questions

Q: Most strongly associated with rheumatoid arthritis among the following is?

HLA DR4. ***HLA DR4*** - **HLA-DR4** is the **MHC Class II allele** most strongly associated with an increased risk and severity of **rheumatoid arthritis (RA)**. - It is thought to contribute to RA pathogenesis by presenting specific peptides that activate **auto-reactive T cells**, initiating the autoimmune response. *HLA B27* - **HLA-B27** is primarily associated with **seronegative spondyloarthropathies**, such as **ankylosing spondylitis** and **reactive arthritis**. - It has no significant association with **rheumatoid arthritis**. *HLA DQ1* - While a variety of **HLA-DQ alleles** are involved in autoimmune diseases, **HLA-DQ1** is not among the primary genetic associations for **rheumatoid arthritis**. - Its pathogenic role is more commonly studied in other conditions, such as **coeliac disease**, though various subtypes exist. *HLA DR8* - **HLA-DR8** has some associations with certain autoimmune conditions, such as **primary biliary cholangitis** and **Crohn's disease**. - It is not considered a primary or strong genetic risk factor for **rheumatoid arthritis**.

Q: In a middle aged male having back pain, syndesmophytes involving4 continous vertebrae are seen on Xray. The patient has -

Ankylosing spondylitis. ***Ankylosing spondylitis*** - The presence of **syndesmophytes** involving four continuous vertebrae on X-ray is virtually pathognomonic for **ankylosing spondylitis**, especially in a middle-aged male with back pain. - **Syndesmophytes** in ankylosing spondylitis are typically **thin, vertical bone outgrowths** arising from the annulus fibrosus, leading to the characteristic "bamboo spine" appearance when extensive. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** primarily affects peripheral synovial joints and does not typically cause **syndesmophytes** in the spine. - Spinal involvement in RA usually manifests as **atlantoaxial subluxation** due to inflammation of ligaments in the cervical spine, not extensive syndesmophyte formation. *DISH* - **Diffuse idiopathic skeletal hyperostosis (DISH)**, also known as Forestier's disease, is characterized by widespread ossification of ligaments and entheses, particularly along the anterolateral aspects of the spine. - Unlike syndesmophytes in ankylosing spondylitis, the bony bridges in DISH are typically **flowy and thicker**, often preserving the disc spaces, and do not arise from the annulus fibrosus in the same way. *Osteoarthritis* - **Osteoarthritis** of the spine (spondylosis) is characterized by **osteophytes** (bone spurs) which are typically horizontal and arise from the vertebral body endplates. - **Osteophytes** in osteoarthritis are distinct from the vertical **syndesmophytes** seen in spondyloarthropathies like ankylosing spondylitis and do not bridge multiple vertebral bodies in the same manner.

Q: In gout tophi are not seen in?

Muscles. ***Muscles*** - **Muscles** are not a typical site for the formation of **tophi** in gout because they have a rich blood supply and are constantly undergoing metabolic activity, aiding in the clearance of uric acid crystals. - Tophaceous deposits primarily occur in tissues with **poor vascularity** and lower temperatures, where uric acid crystals can more easily precipitate and accumulate. *Nasal cartilage* - **Cartilage**, including the **nasal cartilage**, is a common site for tophi due to its **avascular** nature, which allows for easier deposition of **uric acid crystals** [1]. - Tophi in cartilage can manifest as painless or tender nodules. *Skin* - **Skin**, especially around joints or on the ear helix, is a frequent location for **tophi** formation, appearing as subcutaneous nodules [1]. - These deposits are often visible through the skin and can ulcerate if left untreated [1]. *Synovium* - The **synovium** is a primary target of gout, with **uric acid crystal deposition** leading to inflammatory arthritis [2]. - While acute inflammation involves the release of crystals into the synovial fluid, persistent high urate levels can lead to **tophaceous deposits** within the synovial membrane itself, contributing to chronic joint damage [1].

Q: Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Angioneurotic edema. ***Angioneurotic edema*** - The rapid onset of **laryngeal edema**, **stridor**, **hoarseness**, and **tongue swelling** following peanut consumption points to an allergic reaction, specifically **anaphylaxis** causing angioedema [1], [2]. - This is a life-threatening condition due to potential **airway obstruction**. *Foreign body bronchus* - While a foreign body could cause **stridor** if large enough to impact the trachea, symptoms like **laryngeal edema** and **tongue swelling** are not typical. - It usually presents with sudden coughing, wheezing, and possibly dyspnea, often without rapid-onset, diffuse swelling. *Foreign body larynx* - A foreign body in the larynx might cause hoarseness and stridor, but **laryngeal edema** and **tongue swelling** are not primary features of a simple foreign body obstruction. - The history of peanut ingestion and rapid systemic inflammatory response makes an allergic reaction more likely [2]. *Pharyngeal abscess* - A pharyngeal abscess typically develops more slowly, with symptoms including **severe sore throat**, **fever**, and **difficulty swallowing**. - It would not usually present with the rapid onset of severe **laryngeal edema** and **tongue swelling** immediately after peanut consumption.

Q: Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Libman-Sacks endocarditis. ***Libman-Sacks endocarditis*** - Libman-Sacks endocarditis is a **non-infectious valvular vegetation** that is highly characteristic of **systemic lupus erythematosus (SLE)** [3]. - These vegetations can lead to **valvular incompetence** or **stenosis**, primarily affecting the **mitral and aortic valves** [1]. *Mitral valve prolapse* - While mitral valve prolapse can occur in SLE patients, it is a relatively common condition in the general population and is **not as specifically linked** to SLE pathology as Libman-Sacks endocarditis. - It involves the **leaflet(s) of the mitral valve bulging** back into the left atrium during systole, which causes a **mid-systolic click and late systolic murmur**, but does not represent the specific immune-mediated damage seen in SLE. *Hemorrhagic pericarditis* - Pericarditis is a common cardiac manifestation in SLE, leading to **inflammation of the pericardium**, but it is typically **serous or fibrinous**, not usually hemorrhagic. - **Hemorrhagic pericarditis** is more often associated with conditions like malignancy, tuberculosis, or trauma, and is not a typical presentation of SLE. *Infective endocarditis* - **Infective endocarditis** is caused by microbial infection of the heart valves, resulting in **vegetations containing bacteria or fungi** [2]. - While SLE patients can be at increased risk for infections due to immunosuppression, the vegetations of Libman-Sacks endocarditis are **sterile (non-infectious)** and distinct in their underlying pathophysiology [1].

Q: All are true regarding Ankylosing spondylitis except -

More common in females. ***More common in females*** - **Ankylosing spondylitis** (AS) is **more common in males** than females, with a male-to-female ratio typically ranging from 2:1 to 3:1. - While females can be affected, their disease presentation might be milder and diagnosis often delayed. *Sacroilitis* - **Sacroiliitis** is a hallmark feature and often the **earliest radiographic finding** in ankylosing spondylitis, characterized by inflammation of the sacroiliac joints [1]. - It is crucial for the diagnosis of AS, causing **buttock pain** and stiffness [1]. *HLA -B27* - The presence of the **HLA-B27** allele is strongly associated with ankylosing spondylitis, found in **90-95% of Caucasian patients** with AS [1]. - While not diagnostic on its own, it significantly increases the risk and supports the diagnosis in conjunction with clinical and imaging findings [1]. *Iridocyclitis* - **Acute anterior uveitis (iritis or iridocyclitis)** is a common **extra-articular manifestation** of ankylosing spondylitis, affecting approximately 25-40% of patients [1]. - It presents with **eye pain**, redness, and photophobia, and can precede or follow the onset of joint symptoms.

Q: TRUE about arthropathy in hemochromatosis:

It usually occurs after age 50. ***It usually occurs after age 50*** - Hemochromatosis-related arthropathy typically manifests later in life, commonly **after the age of 50**, aligning with the progressive accumulation of iron. - The chronicity of iron overload is necessary for significant joint damage to occur, leading to symptoms in older individuals.*Acute brief attacks usually affects shoulder joints* - Arthropathy in hemochromatosis is generally a **chronic, progressive condition**, not characterized by acute, brief attacks. - While various joints can be affected, the **second and third metacarpophalangeal (MCP) joints** are characteristically the first and most commonly involved, not usually the shoulder.*Lower limb joints are first affected* - The **second and third metacarpophalangeal (MCP) joints** of the hands are classic initial sites of involvement in hemochromatosis arthropathy [1]. - Involvement of lower limb joints, such as the knees and hips, typically occurs later in the disease course.*Arthropathy improves with phlebotomy* - While phlebotomy is crucial for removing excess iron and preventing further organ damage in hemochromatosis, it generally **does not reverse or significantly improve existing arthropathy**. - Joint damage due to iron deposition and subsequent cartilage destruction is often irreversible once established, though phlebotomy can prevent worsening of joint symptoms.

Q: Which of the following is true about psoriatic arthritis

All of the options. ***All of the options*** - **Psoriatic arthritis** is a seronegative spondyloarthropathy [2] that can manifest with a wide range of joint involvement, including **sacroiliitis**, characteristic radiological changes like **pencil-in-cup deformity**, and involvement of both **distal** and **proximal interphalangeal joints** [1]. *Sacroiliitis is a common feature* - **Sacroiliitis** occurs in approximately 20-40% of patients with psoriatic arthritis, contributing to inflammatory back pain. - It is often **asymmetrical** and can be detected radiographically [1], distinguishing it from the typically symmetrical sacroiliitis of ankylosing spondylitis. *Pencil in cup deformity is a radiological finding* - This characteristic radiological finding, known as **arthritis mutilans**, is seen in a severe subtype of psoriatic arthritis where there is **osteolysis** of the phalanx and telescoping of the digit [2]. - It results from severe bone erosion at the joint margins, creating a "pencil-in-cup" appearance. *Involves distal joints of hand and foot and proximal interphalangeal joints* - **DIP joint involvement** (distal interphalangeal) is a classic feature of psoriatic arthritis, distinguishing it from rheumatoid arthritis [1], [2]. - Involvement of the **PIP joints** (proximal interphalangeal) and other peripheral joints is also common [1], along with **dactylitis** (sausage digits) and **enthesitis**.

Q: Bechterew disease is?

Ankylosing spondylitis. ***Ankylosing spondylitis*** - **Bechterew disease** is an older term sometimes used to refer to **ankylosing spondylitis**. [1] - It is a chronic inflammatory disease primarily affecting the **axial skeleton**, including the spine and sacroiliac joints. [1] *Beh''et''s disease* - This is a separate chronic, systemic inflammatory disease characterized by **recurrent oral and genital ulcers**, **skin lesions**, and **ocular involvement**. - It does not primarily affect the spine in the same way as ankylosing spondylitis and is not known as Bechterew disease. *Sjogren''s syndrome* - This is an **autoimmune disease** primarily characterized by **dry eyes** (**xerophthalmia**) and **dry mouth** (**xerostomia**) due to lymphocytic infiltration of exocrine glands. - It is not referred to as Bechterew disease and has distinct clinical features from ankylosing spondylitis. *Psoriasis* - This is a chronic **autoimmune skin condition** characterized by red, scaly patches on the skin, often associated with **psoriatic arthritis**. [1] - While psoriatic arthritis can involve the spine, psoriasis itself is a skin condition and is not synonymous with Bechterew disease. [1]

Q: Behcet's syndrome is characterized by all, Except:

Myocarditis. ***Myocarditis*** - While Behcet's syndrome can affect various organ systems, **cardiac involvement** in the form of myocarditis is **rare** and not a characteristic feature. - Cardiac manifestations are more commonly pericarditis or intracardiac thrombi, not primarily inflammation of the heart muscle itself. *Erythema Nodosum* - **Erythema nodosum** is a common mucocutaneous manifestation of Behcet's syndrome, characterized by **tender, erythematous nodules** typically on the shins. - It is part of the diagnostic criteria and reflects the systemic inflammatory nature of the disease. *Thrombophlebitis* - **Thrombophlebitis**, particularly **venous thrombosis**, is a hallmark feature of Behcet's syndrome due to its characteristic **hypercoagulable state**. - This can affect both superficial and deep veins, sometimes leading to life-threatening complications. *Oral and Genital ulcers* - **Recurrent oral aphthous ulcers** are the **most common and often the first symptom** of Behcet's syndrome, a mandatory criterion for diagnosis. - **Genital ulcers**, specifically aphthous lesions on the scrotum or labia, are also very common and contribute significantly to the diagnostic criteria.

Question 1

Most strongly associated with rheumatoid arthritis among the following is?

Accepted Answer

HLA DR4

Answer

HLA B27

Answer

HLA DQ1

Answer

HLA DR8

Question 2

In a middle aged male having back pain, syndesmophytes involving4 continous vertebrae are seen on Xray. The patient has -

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

DISH

Answer

Osteoarthritis

Question 3

In gout tophi are not seen in?

Accepted Answer

Muscles

Answer

Nasal cartilage

Answer

Skin

Answer

Synovium

Question 4

Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Accepted Answer

Angioneurotic edema

Answer

Foreign body bronchus

Answer

Foreign body larynx

Answer

Pharyngeal abscess

Question 5

Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Accepted Answer

Libman-Sacks endocarditis

Answer

Mitral valve prolapse

Answer

Hemorrhagic pericarditis

Answer

Infective endocarditis

Question 6

All are true regarding Ankylosing spondylitis except -

Accepted Answer

More common in females

Answer

Sacroilitis

Answer

HLA -B27

Answer

Iridocyclitis

Question 7

TRUE about arthropathy in hemochromatosis:

Accepted Answer

It usually occurs after age 50

Answer

Acute brief attacks usually affects shoulder joints

Answer

Lower limb joints are first affected

Answer

Arthropathy improves with phlebotomy

Question 8

Which of the following is true about psoriatic arthritis

Accepted Answer

All of the options

Answer

Sacroiliitis is a common feature

Answer

Pencil in cup deformity is a radiological finding

Answer

Involves distal joints of hand and foot and proximal interphalangeal joints

Question 9

Bechterew disease is?

Accepted Answer

Ankylosing spondylitis

Answer

Behçet's disease

Answer

Sjogren's syndrome

Answer

Psoriasis

Question 10

Behcet's syndrome is characterized by all, Except:

Accepted Answer

Myocarditis

Answer

Erythema Nodosum

Answer

Thrombophlebitis

Answer

Oral and Genital ulcers

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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