Rheumatology and Immunology Practice Questions

Q: Distal interphalangeal joints are involved in all except -

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Rheumatoid arthritis** characteristically spares the **distal interphalangeal (DIP) joints** while commonly affecting the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints [1]. - Involvement of the DIP joints would suggest an alternative diagnosis or atypical presentation [5]. *Psoriatic arthritis* - **Psoriatic arthritis** frequently involves the **DIP joints**, leading to classic "sausage digits" (dactylitis) and nail changes [1]. - It often gives a "pencil-in-cup" appearance on X-ray due to erosions at these joints [3]. *Reactive arthritis* - **Reactive arthritis** can affect any joint, including the **DIP joints**, although it more commonly presents in a **mono- or oligoarticular** pattern, predominantly in the lower limbs [4]. - The pattern of joint involvement is typically asymmetric [4]. *Osteoarthritis* - **Osteoarthritis** commonly affects the **DIP joints**, leading to the formation of **Heberden's nodes** (bony enlargements at the DIP joints) [2]. - This is a hallmark feature of generalized osteoarthritis, especially in the hands [2].

Q: All of the following features may be used to distinguish PAN from microscopic polyangitis, except:

Necrotizing vasculitis. ***Necrotizing vasculitis*** - Both **polyarteritis nodosa (PAN)** and **microscopic polyangiitis (MPA)** are characterized by **necrotizing vasculitis**, making it a shared feature rather than a distinguishing one. [1] - This pathological finding describes the **inflammation** and **necrosis** of vessel walls, which is central to the pathogenesis of both conditions. [1] *RBC cast in urine* - **Red blood cell (RBC) casts** in the urine are indicative of **glomerulonephritis**, which is a prominent feature of **microscopic polyangiitis (MPA)** but typically absent in **polyarteritis nodosa (PAN)**. [1] - The presence of RBC casts points to **renal involvement**, particularly in the small vessels of the glomeruli, which distinguishes MPA's pattern of injury. [1] *ANCA positivity* - **Anti-neutrophil cytoplasmic antibodies (ANCAs)**, particularly **p-ANCA (MPO-ANCA)**, are frequently positive in **microscopic polyangiitis (MPA)** but usually negative in **polyarteritis nodosa (PAN)**. - ANCA positivity helps classify MPA as an **ANCA-associated vasculitis**, a distinction not typically applied to PAN. *HBV infection* - **Hepatitis B virus (HBV) infection** is strongly associated with a significant subset of **polyarteritis nodosa (PAN)** cases, whereas this association is rare in **microscopic polyangiitis (MPA)**. - Serological testing for HBV can therefore help differentiate between the two conditions, with a positive result favoring PAN.

Q: Which of the following is NOT a connective tissue disorder?

Sjogren's syndrome. ***Sjogren's syndrome*** - Sjogren's syndrome is an **autoimmune disease** characterized by **dry eyes** and **dry mouth**, resulting from immune-mediated destruction of exocrine glands [1]. - While it can involve multiple organ systems and is classified as a **systemic autoimmune disorder**, it is primarily an **exocrinopathy**, and not exclusively a disorder of connective tissue structure or function. *Osteoarthritis* - Osteoarthritis is a **degenerative joint disease** primarily affecting the **articular cartilage** and underlying bone. - While it involves destruction of cartilage, which is a connective tissue, it is considered a **degenerative rather than a systemic inflammatory or autoimmune connective tissue disorder**. *Fibromyalgia* - Fibromyalgia is a chronic pain condition characterized by **widespread musculoskeletal pain**, fatigue, and sleep disturbances, without evidence of inflammation or tissue damage [3]. - It is considered a **central sensitization syndrome** rather than a disorder of the connective tissue itself [3]. *SLE* - Systemic lupus erythematosus (SLE) is a **prototypical systemic autoimmune connective tissue disorder** affecting multiple organ systems [2]. - It is characterized by **autoantibody production** and immune complex deposition, leading to inflammation and damage in joints, skin, kidneys, and other tissues [2].

Q: Antibodies most specific for drug induced lupus are -

Antihistone. ***Antihistone*** - **Antihistone antibodies** are present in 95% of patients with **drug-induced lupus erythematosus (DILE)**, making them the most specific marker for this condition. - The disease often resolves upon discontinuation of the culprit drug, and antihistone antibody levels typically decrease. *ANA* - **Antinuclear antibodies (ANA)** are present in nearly all forms of lupus, including DILE, but are **not specific** for drug-induced forms as they are also found in SLE and other autoimmune diseases [1]. - A positive ANA test is often the initial screening test for lupus but requires further, more specific antibody testing for differentiation. *Anti Sm* - **Anti-Smith (Anti-Sm) antibodies** are highly specific for **systemic lupus erythematosus (SLE)** [1], but are rarely seen in DILE. - Their presence strongly suggests a diagnosis of SLE and not drug-induced lupus. *Anti ds DNA* - **Anti-double-stranded DNA (Anti-dsDNA) antibodies** are highly specific for **systemic lupus erythematosus (SLE)** and are often associated with disease activity and **lupus nephritis**. - These antibodies are typically **absent** or present in very low titers in DILE, differentiating it from SLE.

Q: Most common manifestation of rheumatic fever –

Arthritis. ***Arthritis*** - **Polyarthritis** is the most common major manifestation of acute rheumatic fever (ARF), affecting up to 75% of patients. - It typically presents as a **migratory arthritis** affecting large joints such as knees, ankles, elbows, and wrists, resolving without sequelae. *Chorea* - **Sydenham's chorea** (St. Vitus' dance) is a neurological manifestation characterized by sudden, involuntary, jerky movements, occurring in about 10-30% of ARF cases. - While a major criterion, its incidence is significantly lower than that of arthritis. *Carditis* - **Carditis** is the most serious manifestation of ARF, affecting 40-70% of patients and often leading to chronic rheumatic heart disease. - Although it has the highest mortality and morbidity, its frequency is less than that of arthritis. *Nodules* - **Subcutaneous nodules** are rare manifestations of ARF, typically appearing on extensor surfaces of joints or the spine, and are usually painless. - They occur in less than 1-2% of cases, making them one of the least common major criteria.

Q: All of the following are indications for use of corticosteroids in SLE except:

Endocarditis. ***Endocarditis*** - While **Libman-Sacks endocarditis** is a known manifestation of SLE, it typically involves **non-infectious vegetations** and rarely causes significant valvular dysfunction requiring corticosteroid therapy for acute treatment. - Steroids are generally not indicated for the primary treatment of established endocarditis, whether infectious or non-infectious, unless there is a severe active inflammatory component or an autoimmune-driven valvulitis. *Nephritic syndrome* - **Lupus nephritis**, especially the proliferative forms (Class III and IV), often presents with nephritic syndrome and is a **primary indication for aggressive corticosteroid therapy** to suppress inflammation and prevent renal failure [1]. - Corticosteroids are crucial in combination with immunosuppressants to manage renal inflammation, proteinuria, and declining renal function. *Pericarditis* - **Pericarditis** in SLE can be symptomatic and is often managed with **corticosteroids** to reduce inflammation and alleviate chest pain [1]. - Severe or recurrent pericarditis may require higher doses of steroids, and tamponade is a rare but serious complication. *Neuropsychiatric lupus* - Manifestations such as **CNS vasculitis**, **seizures**, psychosis, and severe cognitive dysfunction are considered **major organ involvement** and are treated with **high-dose corticosteroids** to reduce inflammation and prevent permanent neurological damage. - Steroids are often part of the initial treatment regimen for acute and severe neuropsychiatric SLE.

Q: Most specific test for SLE

Anti- smith antibody. ***Anti-smith antibody*** - **Anti-Smith (anti-Sm) antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)**, meaning their presence strongly indicates the disease [1]. - While only present in about 20-30% of SLE patients, they are rarely found in other conditions, making them a key diagnostic marker [1]. *ds-DNA* - **Anti-dsDNA antibodies** are highly specific for SLE and often correlate with **disease activity**, especially **lupus nephritis**. - However, their specificity is slightly lower than anti-Sm antibodies, as they can sometimes be found in other autoimmune conditions (e.g., drug-induced lupus). *ss DNA* - **Anti-ssDNA antibodies** are less specific for SLE and can be found in various other **autoimmune diseases**, infections, and even in healthy individuals. - Therefore, their presence alone is not sufficient for a diagnosis of SLE. *Histone* - **Anti-histone antibodies** are most commonly associated with **drug-induced lupus (DIL)**, found in about 95% of patients with DIL. - While they can be present in some cases of SLE, they are not specific for spontaneous SLE and are a better indicator of DIL.

Q: Which is NOT a feature of polymyositis?

Ocular muscle involvement. ***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.

Q: A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?

Giant cell arteritis. ***Giant cell arteritis*** - This presentation with **severe headache**, **temporal artery tenderness**, and a **decreased pulse** in a 65-year-old patient is highly classic for giant cell arteritis (GCA). GCA characteristically affects **medium and large arteries**, often the **temporal artery**. - **Decreased pulse** can indicate involvement of other large vessels, such as the subclavian artery, which can occur in GCA. Urgent diagnosis and treatment are crucial due to the risk of **permanent vision loss** [1]. *Wegener's granulomatosis* - This condition (**granulomatosis with polyangiitis**) is characterized by **upper and lower respiratory tract granulomatous inflammation**, **glomerulonephritis**, and small vessel vasculitis. - While it can manifest with systemic symptoms, **temporal artery tenderness** and a **decreased pulse** are not primary features of Wegener's. *Microscopic polyangiitis* - This is a **small vessel vasculitis** that primarily affects capillaries, venules, and arterioles. - It typically presents with **glomerulonephritis** and **pulmonary capillaritis**, but without granuloma formation, and does not involve the temporal arteries or lead to a decreased pulse in the manner described. *Takayasu arteritis* - Takayasu arteritis primarily affects the **aorta and its major branches**, leading to **claudication**, **pulse deficits** in the extremities, and often occurs in **younger women**. - While it can cause a decreased pulse, it is less likely to present with **temporal artery tenderness** and severe headache in a 65-year-old, as these symptoms are more characteristic of GCA.

Q: Pleural effusion in rheumatoid arthritis is typically associated with the following features except

Glucose > 60 mg/dl. ***Glucose > 60 mg/dl*** - Pleural effusions in rheumatoid arthritis are typically characterized by **low glucose levels** ( 3 gm/dl* - Rheumatoid pleural effusions are generally **exudative**, meaning they have high protein content, typically greater than 3.0 g/dL. - This high protein level reflects increased capillary permeability and inflammation characteristic of rheumatoid disease. *Pleural fluid LDH to serum LDH ratio of >0.6* - An LDH ratio of pleural fluid to serum greater than 0.6 is a key criterion for an **exudative effusion** based on Light's criteria. - Rheumatoid effusions are almost always exudative, consistent with this elevated LDH ratio. *Pleural fluid protein to serum protein ratio of >0.5* - A pleural fluid protein to serum protein ratio greater than 0.5 also indicates an **exudative effusion**, as per Light's criteria. - This finding is common in rheumatoid pleural effusions due to increased protein leakage into the pleural space from inflammation [1].

Question 1

Distal interphalangeal joints are involved in all except -

Accepted Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Reactive arthritis

Answer

Osteoarthritis

Question 2

All of the following features may be used to distinguish PAN from microscopic polyangitis, except:

Accepted Answer

Necrotizing vasculitis

Answer

RBC cast in urine

Answer

ANCA positivity

Answer

HBV infection

Question 3

Which of the following is NOT a connective tissue disorder?

Accepted Answer

Sjogren's syndrome

Answer

Osteoarthritis

Answer

Fibromyalgia

Answer

SLE

Question 4

Antibodies most specific for drug induced lupus are -

Accepted Answer

Antihistone

Answer

ANA

Answer

Anti Sm

Answer

Anti ds DNA

Question 5

Most common manifestation of rheumatic fever –

Accepted Answer

Arthritis

Answer

Chorea

Answer

Carditis

Answer

Nodules

Question 6

All of the following are indications for use of corticosteroids in SLE except:

Accepted Answer

Endocarditis

Answer

Nephritic syndrome

Answer

Pericarditis

Answer

Neuropsychiatric lupus

Question 7

Most specific test for SLE

Accepted Answer

Anti- smith antibody

Answer

ds- DNA

Answer

ss DNA

Answer

Histone

Question 8

Which is NOT a feature of polymyositis?

Accepted Answer

Ocular muscle involvement

Answer

Proximal muscle weakness

Answer

Elevated serum creatine kinase (CK) levels

Answer

Endomysial inflammation on muscle biopsy

Question 9

A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?

Accepted Answer

Giant cell arteritis

Answer

Wegener's granulomatosis

Answer

Microscopic polyangiitis

Answer

Takayasu arteritis

Question 10

Pleural effusion in rheumatoid arthritis is typically associated with the following features except

Accepted Answer

Glucose > 60 mg/dl

Answer

Protein > 3 gm/dl

Answer

Pleural fluid LDH to serum LDH ratio of >0.6

Answer

Pleural fluid protein to serum protein ratio of >0.5

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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