Rheumatology and Immunology Practice Questions

Q: Seronegative spondarthritides includes all EXCEPT

Rheumatoid arthritis. ***Rheumatoid arthritis*** - Rheumatoid arthritis (RA) is characterized by the presence of **rheumatoid factor (RF)** and/or **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, making it a **seropositive** arthropathy. [1] - While it causes an inflammatory arthritis, its serological markers differentiate it from the seronegative spondyloarthropathies. *Reiter's syndrome* - Reiter's syndrome, now commonly referred to as **reactive arthritis**, is a classic example of a seronegative spondyloarthropathy. [1] - It is often triggered by an infection and is typically **RF-negative** and **HLA-B27 positive**. *Ankylosing spondylitis* - **Ankylosing spondylitis (AS)** is a prototypical seronegative spondyloarthropathy, characterized by inflammation primarily affecting the **spine and sacroiliaciac joints**. [1] - It is defined by the **absence of RF** and **anti-CCP antibodies**, though it is strongly associated with **HLA-B27**. *Psoriatic arthritis* - **Psoriatic arthritis (PsA)** is another member of the seronegative spondyloarthropathies, occurring in individuals with **psoriasis**. [1] - Like other conditions in this group, patients with PsA are typically **negative for RF** and **anti-CCP antibodies**.

Q: Anti-histone antibodies are specific for:

Drug induced lupus. ***Drug induced lupus*** - **Anti-histone antibodies** are highly sensitive (up to 95%) for **drug-induced lupus erythematosus (DILE)**, making them a key diagnostic marker. - DILE typically resolves after discontinuation of the offending drug, and the presence of these antibodies helps differentiate it from systemic lupus erythematosus (SLE) [1]. *Neonatal lupus* - **Neonatal lupus** is associated with **anti-Ro/SSA** and **anti-La/SSB antibodies**, which are passively acquired from the mother [1]. - It primarily presents with skin rash and/or congenital heart block, not typically associated with anti-histone antibodies. *CNS lupus* - **Central nervous system (CNS) lupus** is a manifestation of **systemic lupus erythematosus (SLE)** and is associated with various autoantibodies, including **anti-ribosomal P protein antibodies** and sometimes anti-neuronal antibodies. - While patients with SLE can have anti-histone antibodies, they are not specific for CNS involvement, and other antibody profiles are more relevant to CNS manifestations. *Cutaneous lupus* - **Cutaneous lupus erythematosus (CLE)** can be a standalone condition or part of SLE; it is typically associated with **anti-Ro/SSA antibodies** in subacute cutaneous lupus and sometimes **anti-dsDNA antibodies** in acute cutaneous lupus [2]. - **Anti-histone antibodies** are not a primary diagnostic marker for the various forms of cutaneous lupus.

Q: A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis. (SELECT 1 DIAGNOSIS)

Polyarteritis nodosa. ***Polyarteritis nodosa*** - The combination of **fever**, **weight loss**, **hypertension**, **peripheral neuropathy**, **nodular skin rash**, **elevated ESR**, and **RBC casts** (indicating glomerulonephritis) is highly suggestive of **polyarteritis nodosa**. Systemic vasculitis should be considered in any patient with fever, weight loss, and multisystem involvement [1]. - **Polyarteritis nodosa** is a systemic vasculitis characterized by necrotizing inflammation of medium-sized arteries, often associated with a history of **drug abuse** and can involve multiple organ systems leading to the described symptoms [1]. *Behcet syndrome* - Characterized by recurrent **oral** and **genital ulcers**, and **uveitis**, which are not mentioned in this patient presentation. - While it can manifest with skin lesions and vasculitis, the specific constellation of symptoms, including hypertension and RBC casts, points away from **Behcet syndrome**. *Ankylosing spondylitis* - Primarily affects the **axial skeleton**, causing chronic back pain and stiffness, particularly in younger males. - It does not typically present with the systemic symptoms like **hypertension**, **nodular rash**, or **RBC casts** seen in this patient. *Polymyalgia rheumatica* - Characterized by **proximal muscle pain** and stiffness, predominantly in the shoulders, neck, and hip girdle, in older adults. - It is not associated with **hypertension**, **peripheral neuropathy**, **nodular skin rash**, or **renal involvement** (RBC casts) as described.

Q: In osteoarthritis, Bouchard nodes and Heberden's nodes are seen respectively at:

PIP and DIP. ***PIP and DIP*** - **Bouchard nodes** are bony enlargements of the **proximal interphalangeal (PIP) joints** of the fingers due to osteophyte formation. - **Heberden's nodes** are similar bony enlargements found on the **distal interphalangeal (DIP) joints** of the fingers. *DIP and MCP* - This option incorrectly associates Heberden's nodes with the MCP joints and does not correctly identify the location for Bouchard nodes. - While DIP joints are affected by Heberden's nodes, the **metacarpophalangeal (MCP) joints** are typically spared or less commonly involved in osteoarthritis compared to PIP and DIP joints. *DIP and PIP* - This option incorrectly reverses the locations for Bouchard and Heberden's nodes. - **Bouchard nodes** are found on the **PIP joints**, and **Heberden's nodes** are found on the **DIP joints**. *Palm and DIP* - This option incorrectly identifies the palm as a site for node formation in osteoarthritis. - Osteoarthritis typically affects the **interphalangeal joints** (PIP and DIP) and not the palmar aspect of the hand.

Q: Which of the following conditions is an indication for Chrysotherapy?

Rheumatoid arthritis. The explanation with [3], [1] inline citations added ***Rheumatoid arthritis*** - Chrysotherapy, specifically using **gold salts**, was an early and effective treatment for **rheumatoid arthritis (RA)**, particularly for patients with active and progressive disease. [3] - While less common today due to newer biological agents, gold compounds like **aurothiomalate** and **auranofin** were historically used to reduce inflammation and slow joint damage in RA. [1] *Ankylosing spondylitis* - **Ankylosing spondylitis** is a seronegative spondyloarthropathy primarily affecting the axial skeleton. - Its treatment typically involves **NSAIDs**, **TNF-alpha inhibitors**, and exercise, not chrysotherapy. *Behcet's syndrome* - **Behcet's syndrome** is a systemic vasculitis characterized by recurrent oral ulcers, genital ulcers, and uveitis. - Treatment usually involves **corticosteroids** and **immunosuppressants**, with no indication for chrysotherapy. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease involving cartilage breakdown. [2] - Management focuses on **pain relief**, **physical therapy**, and in severe cases, **joint replacement**, and chrysotherapy is not part of its treatment regimen. [2]

Q: Triple therapy in Rheumatoid Arthritis involves all except

Steroids. ***Steroids*** - While **steroids** (e.g., **prednisone**) are commonly used in rheumatoid arthritis to control flares and bridge therapy [1], they are not a component of the classic "triple therapy" regimen, which refers to a specific combination of **DMARDs**. - Steroids are typically used for their rapid **anti-inflammatory effects** but carry significant long-term side effects, making them unsuitable for sustained monotherapy or as part of continuous fixed-dose DMARD combinations. *Hydroxychloroquine* - **Hydroxychloroquine** is a foundational component of the traditional "triple therapy" for rheumatoid arthritis, valued for its relatively mild side effect profile. - It works by modulating immune responses and is often combined with other **DMARDs** for synergistic effects. *Sulphasalazine* - **Sulphasalazine** is another key component of the "triple therapy" regimen, particularly useful for its anti-inflammatory and immunomodulatory actions in rheumatoid arthritis. - It helps to reduce joint pain, stiffness, and swelling, working in conjunction with methotrexate and hydroxychloroquine. *Methotrexate* - **Methotrexate** is considered the cornerstone of rheumatoid arthritis treatment and is an essential part of the "triple therapy" combination [1]. - It is a **disease-modifying antirheumatic drug (DMARD)** that effectively slows disease progression and reduces joint damage.

Q: Raynaud's phenomenon is commonly seen in

Upper limb of female. Upper limb of female - **Raynaud's phenomenon** is characterized by episodic digital ischemia, primarily affecting the **fingers and toes**. - It is significantly more prevalent in **females** and typically manifests in the **upper limbs** (fingers) due to exposure to cold or stress. *Lower limb of female* - While Raynaud's can affect the lower limbs (**toes**), it is less common as the primary site of presentation. - The classic description and initial manifestations are predominantly in the **fingers**. *Lower limb of male* - Raynaud's phenomenon is **less common in males** compared to females. - When it does occur in males, it is often associated with a **secondary cause**, such as connective tissue diseases. *Upper limb of male* - Raynaud's phenomenon in the upper limbs of males is **less frequent** than in females. - If a male presents with Raynaud's, particularly in the upper limbs, investigation for **underlying diseases** (e.g., scleroderma) is often warranted.

Q: "Flexor tendon tenosynovitis" is a hallmark feature of

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Flexor tendon tenosynovitis** is a common inflammatory manifestation in **rheumatoid arthritis**, contributing to symptoms like trigger finger and carpal tunnel syndrome [2]. - It involves inflammation of the **synovial sheath** surrounding the flexor tendons, often seen in the hands and wrists. *Osteoarthritis* - Primarily a **degenerative joint disease** characterized by cartilage breakdown, not inflammation of tendon sheaths. - While osteophytes can lead to mechanical irritation, primary **tendon tenosynovitis** is not a hallmark. *Psoriatic arthritis* - Characterized by **dactylitis** (sausage digits) and enthesitis (inflammation at tendon/ligament insertions), but **flexor tendon tenosynovitis** itself is less distinctive compared to RA [1]. - It often involves asymmetrical joint inflammation and skin/nail psoriasis [1]. *Ankylosing spondylitis* - A form of **spondyloarthritis** primarily affecting the axial skeleton (spine and sacroiliac joints) and entheses. - **Flexor tendon tenosynovitis** is not a typical or hallmark feature of this condition, which is more associated with spinal stiffness and pain.

Q: Which of the following is NOT a characteristic feature of Henoch-Schönlein purpura (HSP)?

Thrombocytopenia. ***Thrombocytopenia*** - **Thrombocytopenia** is generally **not a feature** of Henoch-Schönlein purpura (HSP); platelet counts are typically **normal** or can even be elevated [1]. - HSP is a **vasculitis**, characterized by **IgA deposition**, leading to palpable purpura, rather than a primary platelet disorder [1]. *Splinter hemorrhage* - **Splinter hemorrhages** are a form of **microembolism** or capillary damage that can occur in various conditions, and while not a cardinal feature, they are more related to vessel damage than thrombocytopenia. - Although less common, any form of **vasculitis-related capillary leakage** could theoretically lead to small hemorrhagic phenomena. *Abdominal pain* - **Abdominal pain** is a very common and significant symptom in HSP, often due to **gastrointestinal vasculitis** leading to bowel wall edema, hemorrhage, or intussusception. - It can range from mild discomfort to severe, colicky pain and may be accompanied by **gastrointestinal bleeding**. *Epistaxis* - **Epistaxis** (nosebleeds) is a possible manifestation of **mucosal vasculitis** in HSP. - It can occur due to damage to superficial blood vessels in the nasal passages as part of the systemic inflammatory process.

Q: All are clinical manifestations of Felty's syndrome except:

Nephropathy. ***Nephropathy*** - **Nephropathy** is not a characteristic clinical manifestation of **Felty's syndrome**. While patients with **rheumatoid arthritis** can develop kidney involvement (e.g., secondary amyloidosis) [1], it is not considered part of the core diagnostic criteria or classic presentation of **Felty's syndrome**. - The syndrome specifically involves a triad of features linked to the immune system's overactivity, rather than direct kidney damage. *Neutropenia* - **Neutropenia** (low neutrophil count) is a hallmark feature of **Felty's syndrome**, leading to an increased risk of infections. - It results from the destruction of neutrophils and suppression of bone marrow granulopoiesis. *Rheumatoid arthritis* - **Felty's syndrome** is a severe extra-articular manifestation of **long-standing rheumatoid arthritis**, indicating that the presence of **RA** is a prerequisite [1]. - Patients typically have **seropositive, erosive rheumatoid arthritis** that has been active for many years [1]. *Splenomegaly* - **Splenomegaly** (enlarged spleen) is another key component of **Felty's syndrome**, contributing to the destruction of blood cells [1]. - The enlarged spleen can sequester and destroy neutrophils, further contributing to the neutropenia.

Question 1

Seronegative spondarthritides includes all EXCEPT

Accepted Answer

Rheumatoid arthritis

Answer

Reiter's syndrome

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Question 2

Anti-histone antibodies are specific for:

Accepted Answer

Drug induced lupus

Answer

Neonatal lupus

Answer

CNS lupus

Answer

Cutaneous lupus

Question 3

A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis. (SELECT 1 DIAGNOSIS)

Accepted Answer

Polyarteritis nodosa

Answer

Behcet syndrome

Answer

Ankylosing spondylitis

Answer

Polymyalgia rheumatica

Question 4

In osteoarthritis, Bouchard nodes and Heberden's nodes are seen respectively at:

Accepted Answer

PIP and DIP

Answer

DIP and MCP

Answer

DIP and PIP

Answer

Palm and DIP

Question 5

Which of the following conditions is an indication for Chrysotherapy?

Accepted Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Behcet's syndrome

Answer

Osteoarthritis

Question 6

Triple therapy in Rheumatoid Arthritis involves all except

Accepted Answer

Steroids

Answer

Hydroxychloroquine

Answer

Sulphasalazine

Answer

Methotrexate

Question 7

Raynaud's phenomenon is commonly seen in

Accepted Answer

Upper limb of female

Answer

Lower limb of female

Answer

Lower limb of male

Answer

Upper limb of male

Question 8

"Flexor tendon tenosynovitis" is a hallmark feature of

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Answer

Ankylosing spondylitis

Question 9

Which of the following is NOT a characteristic feature of Henoch-Schönlein purpura (HSP)?

Accepted Answer

Thrombocytopenia

Answer

Splinter hemorrhage

Answer

Abdominal pain

Answer

Epistaxis

Question 10

All are clinical manifestations of Felty's syndrome except:

Accepted Answer

Nephropathy

Answer

Neutropenia

Answer

Rheumatoid arthritis

Answer

Splenomegaly

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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