Rheumatology and Immunology Practice Questions

Q: "Telescope fingers" occur in

Psoriatic arthritis. ### Psoriatic arthritis - **Telescoping fingers**, also known as **arthritis mutilans**, is a severe and rare form of psoriatic arthritis where bone resorption leads to shortening and collapse of digits [1]. - This extreme joint erosion and destruction result in the characteristic "opera glass" or "telescopic" appearance of the fingers and toes [1]. *Reiter's arthritis* - Reiter's arthritis, now known as **reactive arthritis**, is characterized by the triad of **urethritis**, **arthritis**, and **conjunctivitis**. - While it can cause dactylitis ("sausage digits"), it does not typically lead to the severe bone resorption and telescoping seen in arthritis mutilans. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease that can develop after a Group A Streptococcus infection, primarily affecting the heart, joints, brain, and skin. - It causes a **migratory polyarthritis** that is typically acute and self-limiting, without permanent joint damage or deformities like telescoping fingers. *Rheumatoid arthritis* - **Rheumatoid arthritis** is a chronic inflammatory autoimmune disease primarily affecting the synovial lining of joints, leading to painful swelling, bone erosion, and joint deformity. - While it can cause severe joint destruction and deformities like **swan-neck** and **boutonnière** deformities, true "telescoping fingers" (arthritis mutilans) are not characteristic of rheumatoid arthritis.

Q: An elderly male presents with pain in his shoulders and hands. ESR is 105 mm/L. History includes transient blindness and unilateral headache.

Polymyalgia rheumatica. ***Polymyalgia rheumatica*** - The combination of **shoulder and hand pain** in an elderly male, along with a **very high ESR**, is highly suggestive of polymyalgia rheumatica [1]. - **Sudden transient blindness** and **unilateral headache** are concerning for giant cell arteritis, which is often associated with polymyalgia rheumatica and requires prompt treatment. *Polyarteritis nodosa* - This is a **necrotizing vasculitis** of medium-sized arteries, often presenting with systemic symptoms, **renal involvement**, and **neuropathy**. - It typically does not cause shoulder and hand pain as the primary presenting symptom, and the transient blindness and headache are more characteristic of giant cell arteritis. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton**, causing **inflammatory back pain** and stiffness, particularly in younger individuals [2]. - It does not typically present with shoulder and hand pain, transient blindness, or a temporal headache in an elderly patient. *Behçet syndrome* - Characterized by **recurrent oral and genital ulcers**, **uveitis**, and **skin lesions**. - The presenting symptoms of shoulder and hand pain, high ESR, transient blindness, and unilateral headache are not typical features of Behçet syndrome.

Q: Which of the following is a 'Small Vessel Vasculitis':

Microscopic polyangitis. ***Microscopic polyangitis*** - This is a form of **ANCA-associated vasculitis** that primarily affects **small vessels** (capillaries, venules, and arterioles) [1]. - It is characterized by **necrotizing vasculitis** within these small vessels, often presenting with features like **glomerulonephritis** and **pulmonary hemorrhage** [1]. *Takayasu's Disease* - This is a **large vessel vasculitis** that primarily affects the **aorta** and its major branches [1]. - It often presents with symptoms related to **ischemia** in the upper limbs or head, such as claudication or syncope. *Polyaeritis Nodosa (PAN)* - This is a **medium-sized vessel vasculitis** that typically spares capillaries, venules, and arterioles, distinguishing it from small vessel vasculitis [1]. - It classically presents as a **necrotizing vasculitis** affecting multiple organs, often without affecting the lungs or glomeruli significantly. *Giant cell vasculitis* - Also known as **Temporal Arteritis**, this is a **large vessel vasculitis** affecting the aorta and its major branches, particularly the branches of the **carotid artery** [1]. - It is characterized by the presence of **giant cells** in the inflamed vessel wall and is a common cause of **headache**, **jaw claudication**, and **vision loss** in older adults.

Q: All of the following are found in SLE except

Leucocytosis. ***Leucocytosis*** - **Leucopenia** (decreased white blood cell count) is a common hematological manifestation in SLE, not **leucocytosis**. - A persistent white blood cell count of **less than 4,000/mm³** on two or more occasions in the absence of other causes is a criterion for SLE. *Psychosis* - **Neuropsychiatric manifestations**, including psychosis, are recognized as a serious complication of SLE, categorized under **neuropsychiatric SLE (NPSLE)**. - These symptoms result from **inflammation, autoantibody production**, and other immune-mediated processes affecting the central nervous system [1]. *Oral ulcers* - **Oral or nasopharyngeal ulcers** are a common mucocutaneous manifestation of SLE. - These ulcers are typically **painless** and can be found on the **hard palate** or buccal mucosa. *Discoid rash* - A **discoid rash** is a specific skin manifestation of cutaneous lupus, often chronic and causing scarring [1]. - It presents as **erythematous raised patches with adherent keratotic scaling** and follicular plugging, which can lead to scarring alopecia [1].

Q: Antibody in drug induced Lupus

Anti-Histone. ***Anti-Histone*** - **Anti-histone antibodies** are present in 95% of patients with **drug-induced lupus erythematosus (DILE)**, making them the most characteristic serological marker. - They target nuclear proteins (histones) and are crucial for diagnosing DILE. *Anti-smith* - **Anti-Smith antibodies** are highly specific for **systemic lupus erythematosus (SLE)** [1], but not typically associated with drug-induced forms. - Their presence helps distinguish SLE from other autoimmune conditions and drug-induced reactions [1]. *Anti-phospholipid* - **Anti-phospholipid antibodies** are associated with **Antiphospholipid Syndrome (APS)**, an autoimmune disorder causing thrombosis and recurrent pregnancy loss [1]. - While they can be found in a minority of SLE patients, they are not specific to DILE [1]. *Anti-Ribosomal* - **Anti-ribosomal P antibodies** are often found in patients with **SLE**, particularly those with associated **neuropsychiatric symptoms** or **renal involvement**. - They are not a hallmark of drug-induced lupus and are more indicative of idiopathic SLE.

Q: Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?

Symmetrical muscle weakness.. ***Symmetrical muscle weakness.*** - **Muscle weakness** is not a primary diagnostic criterion for **rheumatoid arthritis (RA)** [1]. While muscle atrophy can occur secondary to chronic inflammation and disuse, it's not a defining feature used in diagnostic classification. Symmetrical proximal muscle weakness is instead a hallmark of conditions like polymyositis [2]. - The diagnostic criteria focus on **inflammatory arthritis**, joint involvement patterns, serological markers, and acute phase reactants [1]. *Raised rheumatoid factor.* - The presence of **rheumatoid factor (RF)**, especially in high titers, is a key serological marker for RA, included in the diagnostic criteria [1]. - While not exclusive to RA, its presence aids in confirming the diagnosis, particularly in conjunction with clinical symptoms. *Symmetric swelling (arthritis) for at least 6 weeks.* - **Symmetric polyarthritis**, particularly affecting the **small joints** of the hands and feet, is a hallmark clinical presentation of RA and a central diagnostic criterion [1], [3]. - The **duration of at least 6 weeks** helps differentiate RA from transient or acute forms of arthritis [1]. *Rheumatoid nodules.* - **Rheumatoid nodules**, subcutaneous swellings typically found over bony prominences, are a characteristic extra-articular manifestation of RA and are included [4]. - Their presence indicates more severe disease and is highly specific for RA [4].

Q: Sjogren's syndrome includes all except:

Lymphoma. Sjogren's syndrome includes all except: ***Lymphoma*** - While patients with **Sjogren's syndrome** have a significantly **increased risk of developing lymphoma** (particularly MALT lymphoma), lymphoma itself is not considered one of the primary diagnostic features or components of the syndrome. - Sjogren's syndrome is an **autoimmune disease** characterized by immune-mediated destruction of exocrine glands, leading to sicca symptoms. *Keratoconjunctivitis* - This is a hallmark feature of Sjogren's syndrome, referring to **dry eyes** due to reduced lacrimal gland function. - The sensation of **gritty eyes** or foreign body sensation is common. *Xerostomia* - This symptom, commonly known as **dry mouth**, is a classic manifestation of Sjogren's syndrome resulting from inflammation and damage to the salivary glands. - Patients often report difficulty chewing, swallowing, and speaking. *Arthritis* - **Arthralgia** (joint pain) and **non-erosive arthritis** are common systemic manifestations observed in patients with Sjogren's syndrome. - This joint involvement is typically **symmetrical** and affects the small joints, similar to rheumatoid arthritis but usually without the destructive changes.

Q: A 34-year-old woman has Raynaud's phenomenon associated with systemic sclerosis (scleroderma). Which of the following is the most appropriate management for this condition?

calcium channel blockers (nifedipine). ***Calcium channel blockers (nifedipine)*** - This is **secondary Raynaud's phenomenon** (associated with systemic sclerosis/scleroderma), which is more severe than primary RP due to **structural vascular changes** — intimal fibrosis and obliterative vasculopathy. - **Calcium channel blockers (CCBs), especially nifedipine**, are the **first-line pharmacological treatment** for secondary RP per ACR/EULAR guidelines. They act by causing **vasodilation**, reducing the frequency and severity of vasospastic attacks. - Non-pharmacological measures alone are insufficient in scleroderma-associated RP; pharmacological therapy is almost always required. *Warm clothing* - Warm clothing and cold avoidance are important **non-pharmacological adjuncts** in all forms of Raynaud's, but they are **not sufficient as sole management** in secondary RP associated with systemic sclerosis. - They are appropriate initial measures for **primary Raynaud's** (where attacks are mild and no underlying disease exists). *Ergotamine* - **Ergotamine** is a potent **vasoconstrictor** and is absolutely **contraindicated** in Raynaud's phenomenon. - It would precipitate and worsen vasospastic attacks, potentially leading to digital ischemia. - Its primary use is in **migraine treatment**. *Beta-blocking drugs* - **Beta-blockers** block β2-adrenergic receptors (which mediate vasodilation), leaving **unopposed α-adrenergic vasoconstriction** — worsening Raynaud's. - They are **contraindicated** in Raynaud's phenomenon and should be avoided in these patients. - If a patient with Raynaud's requires antihypertensive therapy, CCBs are doubly beneficial (treating both hypertension and RP).

Q: Which of the following manifestation of rheumatic fever disappears completely?

Arthritis. Arthritis - **Arthritis** in rheumatic fever is typically migratory, affecting large joints, and is self-limiting, resolving completely without chronic damage. - It is one of the **major Jones criteria** but usually leaves no residual joint deformity or functional impairment. *Chorea* - **Sydenham's chorea**, also known as **St. Vitus' dance**, can persist for several weeks or months and may **recur in about one-third of patients**, though it often resolves completely over time [1]. - While it typically resolves, some patients may experience subtle neurological or psychological sequelae. *Carditis* - **Carditis** is the most serious manifestation of rheumatic fever and can lead to **permanent valvular damage**, known as **rheumatic heart disease** [1], [2]. - It often results in **chronic cardiovascular complications** that do not disappear completely [2]. *Subcutaneous nodules* - **Subcutaneous nodules** are typically firm, painless lesions that appear over bony prominences. - While they usually **resolve within weeks**, they are a sign of severe rheumatic fever and can be associated with more serious complications like carditis, indicating a more significant inflammatory process.

Q: A 35 year old lady complains of dysphagia, Raynaud's phenomenon and her hands show the following appearance. Investigations show positive ANA. The likely diagnosis is

Systemic sclerosis. ***Systemic sclerosis*** - The combination of **dysphagia**, **Raynaud's phenomenon**, characteristic hand appearance (sclerodactyly), and **positive ANA** are hallmark features of systemic sclerosis. - This condition is characterized by **fibrosis** of the skin and internal organs, leading to symptoms like dysphagia due to esophageal involvement. *Systemic lupus erythematosus* - While **ANA is positive**, symptoms like dysphagia and severe Raynaud's, particularly with sclerodactyly, are less typical. - SLE often presents with **malar rash**, arthritis, serositis, and renal involvement. *Mixed connective tissue disorder* - This syndrome features overlapping symptoms of SLE, systemic sclerosis, and polymyositis, and a **positive ANA** is common. - However, the specific constellation of **prominent dysphagia**, severe Raynaud's, and the described hand changes point more directly to systemic sclerosis. *Rheumatoid arthritis* - Rheumatoid arthritis is primarily an **inflammatory arthritis**, causing joint pain, swelling, and morning stiffness. - While Raynaud's can occur, **dysphagia** and diffuse skin thickening are not typical features.

Question 1

"Telescope fingers" occur in

Accepted Answer

Psoriatic arthritis

Answer

Reiter's arthritis

Answer

Rheumatic fever

Answer

Rheumatoid arthritis

Question 2

An elderly male presents with pain in his shoulders and hands. ESR is 105 mm/L. History includes transient blindness and unilateral headache.

Accepted Answer

Polymyalgia rheumatica

Answer

Polyarteritis nodosa

Answer

Ankylosing spondylitis

Answer

Behçet syndrome

Question 3

Which of the following is a 'Small Vessel Vasculitis':

Accepted Answer

Microscopic polyangitis

Answer

Takayasu's Disease

Answer

Polyaeritis Nodosa (PAN)

Answer

Giant cell vasculitis

Question 4

All of the following are found in SLE except

Accepted Answer

Leucocytosis

Answer

Psychosis

Answer

Discoid rash

Answer

Oral ulcers

Question 5

Antibody in drug induced Lupus

Accepted Answer

Anti-Histone

Answer

Anti-smith

Answer

Anti-phospholipid

Answer

Anti-Ribosomal

Question 6

Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?

Accepted Answer

Symmetrical muscle weakness.

Answer

Raised rheumatoid factor.

Answer

Symmetric swelling (arthritis) for at least 6 weeks.

Answer

Rheumatoid nodules.

Question 7

Sjogren's syndrome includes all except:

Accepted Answer

Lymphoma

Answer

Keratoconjunctivitis

Answer

Xerostomia

Answer

Arthritis

Question 8

A 34-year-old woman has Raynaud's phenomenon associated with systemic sclerosis (scleroderma). Which of the following is the most appropriate management for this condition?

Accepted Answer

calcium channel blockers (nifedipine)

Answer

warm clothing

Answer

ergotamine

Answer

beta-blocking drugs

Question 9

Which of the following manifestation of rheumatic fever disappears completely?

Accepted Answer

Arthritis

Answer

Chorea

Answer

Carditis

Answer

Subcutaneous nodules

Question 10

A 35 year old lady complains of dysphagia, Raynaud's phenomenon and her hands show the following appearance. Investigations show positive ANA. The likely diagnosis is

Accepted Answer

Systemic sclerosis

Answer

Systemic lupus erythematosus

Answer

Mixed connective tissue disorder

Answer

Rheumatoid arthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

On this page

Practice by Chapter

Want unlimited practice?