Rheumatology and Immunology Practice Questions

Q: Bamboo spine with sacroilitis -

Ankylosing spondylitis. ***Ankylosing spondylitis*** - **Bamboo spine** is a classic radiographic finding in advanced **ankylosing spondylitis**, resulting from ossification of the anulus fibrosus and spinal ligaments [1]. - **Sacroiliitis**, inflammation of the sacroiliac joints, is another hallmark feature and often the earliest radiographic sign of the disease [1], [3]. *Psoriatic arthritis* - While psoriatic arthritis can involve the spine and cause sacroiliitis, it typically presents with **asymmetric involvement** [2] and is less commonly associated with the widespread, progressive ossification characteristic of true "bamboo spine" [4]. - It often also involves **skin psoriasis** and **nail changes**, which are not indicated as the primary finding here [4]. *OA* - **Osteoarthritis (OA)** is a degenerative joint disease characterized by cartilage loss and osteophyte formation, often seen in weight-bearing joints and the spine [2]. - While OA can affect spinal joints and cause stiffness, it does **not cause inflammatory sacroiliitis** or the specific syndesmophyte formation that leads to "bamboo spine." *RA* - **Rheumatoid arthritis (RA)** primarily affects peripheral joints, particularly small joints of the hands and feet, and typically spares the sacroiliac joints and the thoracolumbar spine [2]. - Spinal involvement in RA is usually limited to the **cervical spine**, leading to atlantoaxial subluxation, and does not cause "bamboo spine" or widespread sacroiliitis.

Q: A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?

Decreased chest wall expansion. Decreased chest wall expansion - The patient's symptoms of morning back pain relieved by activity and warm baths are classic for ankylosing spondylitis. This condition commonly leads to fusion of the costovertebral joints, limiting chest wall expansion [1]. - Reduced chest wall expansion is a specific finding in ankylosing spondylitis, reflecting the ankylosis of the axial skeleton and enthesitis at various sites, including rib attachments [1]. Marrow fibrosis - Myelofibrosis is a bone marrow disorder characterized by fibrosis, typically leading to symptoms like fatigue, splenomegaly, and cytopenias, and is not directly associated with ankylosing spondylitis. - While inflammatory conditions can rarely cause reactive changes in bone marrow, widespread fibrosis is not a hallmark or common feature of ankylosing spondylitis. Pleural nodules - Pleural nodules are more characteristic of conditions like rheumatoid arthritis (rheumatoid nodules) or various lung malignancies/infections. - Although lung involvement, such as apical pulmonary fibrosis, can occur in ankylosing spondylitis, discrete pleural nodules are not common. Distal phalangeal joint involvement - Involvement of the distal interphalangeal (DIP) joints is a hallmark feature of psoriatic arthritis [2]. - Ankylosing spondylitis primarily affects the axial skeleton (spine and sacroiliac joints) and large peripheral joints, with DIP joint involvement being very rare [2].

Q: A 25-year-old man complains of low backache, decreased lumbar movements, morning stiffness, which clinical examination will further help:

Chest expansion. ***Chest expansion*** - In **ankylosing spondylitis** (suggested by the young age, low backache, decreased lumbar movements, and morning stiffness), **chest wall restriction** is common due to enthesitis of the costovertebral and sternocostal joints [1]. - Measuring **chest expansion** helps assess the degree of involvement and progression of the disease [1]. *Head circumference* - This measurement is typically used in the assessment of **pediatric growth and development** or certain neurological conditions, not relevant for adult back pain. - It provides no diagnostic information for conditions affecting the spine and joints. *Plantar arch* - Assessment of the **plantar arch** relates to foot mechanics and conditions like **pes planus (flat feet)** or **pes cavus (high arches)**. - While foot problems can cause pain, they are not directly linked to the typical presentation of inflammatory spondyloarthropathies affecting the lumbar spine. *Hyperextension of joints* - **Joint hyperextension** (hypermobility) is characteristic of conditions like **Ehlers-Danlos syndrome** or other hypermobility syndromes [2]. - The patient's symptoms of decreased lumbar movements and stiffness are actually the opposite of hypermobility.

Q: Extra articular manifestation of rheumatoid arthritis is:

Subcutaneous nodules. **Subcutaneous nodules** - **Subcutaneous nodules** are a common **extra-articular manifestation** of rheumatoid arthritis [1], particularly seen in patients with high titers of **rheumatoid factor**. - These firm, non-tender nodules often appear over **pressure points** like the elbows, hands, and Achilles tendons [1]. *Av fistula* - An **arteriovenous (AV) fistula** is a surgically created connection between an artery and a vein, primarily used for **hemodialysis access**, and is not an extra-articular manifestation of rheumatoid arthritis. - While patients with chronic diseases like RA may develop kidney disease requiring dialysis, the fistula itself is a **treatment intervention**, not a disease manifestation. *Splenic atrophy* - **Splenic atrophy** (or hyposplenism) is not a typical extra-articular manifestation of rheumatoid arthritis. - **Felty's syndrome**, a rare, severe form of RA, involves **splenomegaly** (enlarged spleen) along with neutropenia and arthritis, rather than splenic atrophy [2]. *Cutaneous hypomelanosis* - **Cutaneous hypomelanosis** refers to patches of skin with reduced pigmentation and is not a recognized extra-articular manifestation of rheumatoid arthritis. - While some skin changes can occur in RA (e.g., vasculitis, rheumatoid nodules in the skin), **pigmentation disorders** are not characteristic.

Q: Limited cutaneous systemic sclerosis have the following characteristic autoantibody positivity:

Anticentromere. ***Anticentromere*** - **Anticentromere antibodies (ACA)** are highly specific for **limited cutaneous systemic sclerosis (lcSSc)**, also known as **CREST syndrome** [1]. - Their presence correlates with a lower risk of **internal organ fibrosis** but a higher risk of **pulmonary hypertension** and **primary biliary cholangitis** [1]. *Anti-RNA polymerase III* - **Anti-RNA polymerase III antibodies** are typically associated with the **diffuse cutaneous systemic sclerosis (dcSSc)** subtype. - They are linked to an increased risk of **renal crisis** and **malignancy**. *Anti Topoisomerase I* - Also known as **anti-Scl-70 antibodies**, these are strongly associated with **diffuse cutaneous systemic sclerosis (dcSSc)**. - They indicate a higher risk of **pulmonary fibrosis** and **severe skin disease**. *Anti-U3-RNP (fibrillarin)* - **Anti-U3-RNP (fibrillarin) antibodies** are found in a subset of patients with **diffuse cutaneous systemic sclerosis (dcSSc)**. - They are associated with a higher likelihood of **myositis**, **pulmonary hypertension**, and **cardiac involvement**.

Q: Sicca syndrome is associated with all except?

Midline granuloma. Sicca syndrome is associated with all except? ***Midline granuloma*** - **Midline granuloma** (now commonly referred to as **extranodal NK/T-cell lymphoma, nasal type**) is a destructive inflammatory process primarily affecting the upper respiratory tract. It is not directly associated with the autoimmune features of sicca syndrome. - Its pathology involves an aggressive **lymphoproliferative disorder**, distinct from the glandular dysfunction seen in sicca syndrome. *Chronic active hepatitis* - **Primary biliary cholangitis** (formerly primary biliary cirrhosis), a form of chronic active hepatitis, is strongly associated with sicca syndrome. Patients often experience dry eyes and mouth alongside liver involvement. - Autoimmune hepatitis can also present with **extraglandular manifestations** including sicca symptoms, highlighting a systemic autoimmune link. *Rheumatoid arthritis* - **Secondary Sjögren's syndrome**, which manifests as sicca symptoms, commonly occurs in patients with **rheumatoid arthritis (RA)**. This is a well-recognized overlap. - The inflammatory processes common to both conditions suggest a shared **autoimmune pathogenesis**. *Scleroderma* - **Systemic sclerosis (scleroderma)** is another autoimmune connective tissue disease that frequently overlaps with Sjögren's syndrome and features of sicca [1]. - Patients with scleroderma often report **dry eyes and mouth**, reflecting autoimmune involvement of the exocrine glands.

Q: Which is the best investigation to confirm diagnosis of anaphylaxis?

Serum tryptase. ***Serum tryptase*** - **Serum tryptase** is released from activated mast cells and is a reliable biomarker for confirming anaphylaxis, particularly when measured within 1-3 hours of symptom onset. - Elevated levels help differentiate anaphylaxis from other conditions with similar symptoms, especially when the clinical picture is ambiguous. *IgA levels* - **IgA levels** are relevant in diagnosing conditions like selective IgA deficiency or celiac disease, but they do not play a direct role in confirming acute anaphylaxis. - They reflect long-term immune status rather than immediate hypersensitivity reactions. *IgD levels* - **IgD levels** have no established role in the diagnosis or confirmation of anaphylaxis. - Their physiological function is not fully understood, but they are not used as biomarkers for acute allergic reactions. *Serum precipitins* - **Serum precipitins** are antibodies detected in various hypersensitivity reactions, especially to inhaled antigens, and are not specific for anaphylaxis [1]. - They are primarily associated with conditions like hypersensitivity pneumonitis, reflecting different immunological mechanisms [1].

Q: Raynaud's phenomenon seen in all EXCEPT:

Juvenile rheumatoid arthritis. ***Juvenile rheumatoid arthritis*** - While other **rheumatic conditions** are often associated with Raynaud's phenomenon, **juvenile idiopathic arthritis (JIA)**, including the category once known as **juvenile rheumatoid arthritis**, is generally not a common cause [2]. - Its pathophysiology primarily involves **joint inflammation** rather than **vasospastic disorders**. *Scleroderma* - Raynaud's phenomenon is a **hallmark symptom** in nearly all patients with **scleroderma**, often preceding other symptoms by years [3]. - It results from **fibrosis and structural changes** in small blood vessels, leading to exaggerated vasoconstriction [3]. *SLE* - **Systemic lupus erythematosus (SLE)** is frequently associated with Raynaud's phenomenon, occurring in about 20-30% of patients [1]. - It is part of the broader **vasculopathy** seen in autoimmune diseases. *Dermatomyositis* - Raynaud's phenomenon can occur in patients with **dermatomyositis**, though less frequently than in scleroderma (around 15-20%). - Its presence often indicates a more complex **autoimmune overlap syndrome**.

Q: HLA B27 is associated with all except: a) Ankylosing spondylitis b) Pernicious anemia c) Behcet's syndrome d) Reiter's syndrome

Behcet's syndrome. ***Behcet's syndrome*** - While Behcet's syndrome is an inflammatory condition, it is **not typically associated with HLA-B27**. It is more commonly linked to **HLA-B51**. - Its clinical presentation involves recurrent oral and genital ulcers, uveitis, and skin lesions, which are distinct from the spondyloarthritis spectrum. *Ankylosing spondylitis* - This is a classic **HLA-B27 associated spondyloarthropathy**, characterized by chronic inflammation of the sacroiliac joints and spine [1]. - The presence of HLA-B27 significantly increases susceptibility to this condition. *Reiter's syndrome* - Now more commonly referred to as **Reactive Arthritis**, this condition is strongly associated with **HLA-B27** [1]. - It often presents with a triad of arthritis, urethritis, and conjunctivitis following a genitourinary or gastrointestinal infection. *Psoriatic arthritis* - While not as strongly linked as ankylosing spondylitis or reactive arthritis, about **30-50% of patients with psoriatic arthritis test positive for HLA-B27**, especially those with spinal involvement [1]. - It is an inflammatory arthritis associated with **psoriasis** and can affect peripheral joints, the spine, and entheses.

Question 1

Bamboo spine with sacroilitis -

Accepted Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Answer

OA

Answer

RA

Question 2

A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?

Accepted Answer

Decreased chest wall expansion

Answer

Marrow fibrosis

Answer

Pleural nodules

Answer

Distal phalangeal joint involvement

Question 3

A 25-year-old man complains of low backache, decreased lumbar movements, morning stiffness, which clinical examination will further help:

Accepted Answer

Chest expansion

Answer

Head circumference

Answer

Plantar arch

Answer

Hyperextension of joints

Question 4

Extra articular manifestation of rheumatoid arthritis is:

Accepted Answer

Subcutaneous nodules

Answer

Av fistula

Answer

Splenic atrophy

Answer

Cutaneous hypomelanosis

Question 5

Limited cutaneous systemic sclerosis have the following characteristic autoantibody positivity:

Accepted Answer

Anticentromere

Answer

Anti-RNA polymerase III

Answer

Anti Topoisomerase I

Answer

Anti-U3-RNP (fibrillarin)

Question 6

Sicca syndrome is associated with all except?

Accepted Answer

Midline granuloma

Answer

Chronic active hepatitis

Answer

Rheumatoid arthritis

Answer

Scleroderma

Question 7

Which is the best investigation to confirm diagnosis of anaphylaxis?

Accepted Answer

Serum tryptase

Answer

IgA levels

Answer

IgD levels

Answer

Serum precipitins

Question 8

Raynaud's phenomenon seen in all EXCEPT:

Accepted Answer

Juvenile rheumatoid arthritis

Answer

Scleroderma

Answer

SLE

Answer

Dermatomyositis

Question 9

HLA B27 is associated with all except:
a) Ankylosing spondylitis
b) Pernicious anemia
c) Behcet's syndrome
d) Reiter's syndrome

Accepted Answer

Behcet's syndrome

Answer

Ankylosing spondylitis

Answer

Reiter's syndrome

Answer

Psoriatic arthritis

Question 10

Which is a minor criterion for diagnosis of RF according to modified Jones criteria?

Accepted Answer

Fever

Answer

Past History of Rheumatic Fever

Answer

Subcutaneous nodules

Answer

ASO titre

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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