Rheumatology and Immunology — MCQs

A 48-year-old female presents to your office with a 1-year history of dry eyes and difficulty swallowing. She complains of blinking frequently and of eye strain while using her computer at work. She also reports stiffness in her knees and lower back. Past medical history is unremarkable and she does not take medications. She denies cigarette or alcohol use. Family history is notable for Hashimoto's thyroiditis in her mother. Physical exam shows dry oral mucosa and enlargement of the parotid glands. Which of the following serologies is likely to be positive in this patient?

Q636

A lady, when exposed to cold, experiences extremities turning blue. Which of the following antibodies is associated with this condition?

Q637

Which of the following is the best investigation for acute gout?

Q638

Diagnosis of Gout is confirmed by which test?

Q639

Arthritis mutilans is seen in?

Q640

The primary goal of glucocorticoid treatment in rheumatoid arthritis is:

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 631: A young patient presents to the clinic with erythematous lesions over the exposed areas of the skin like hands, arms, chest, etc. she also complaints of arthralgia and breathlessness. Which among the following antibodies will be useful in diagnosing this condition?

A. Anti-centromere antibodies
B. Anti-RNP antibodies
C. Anti-dsDNA antibodies (Correct Answer)
D. Anti-Scl 70 antibodies

Explanation: Anti-dsDNA antibodies - The clinical presentation with erythematous lesions in sun-exposed areas (consistent with photosensitivity [1] or malar rash), arthralgia, and breathlessness (suggesting serositis [4] or pulmonary involvement) is highly suggestive of Systemic Lupus Erythematosus (SLE) [3]. - Anti-dsDNA antibodies are highly specific for SLE and are included in the diagnostic criteria [4]. Their levels often correlate with disease activity, especially in lupus nephritis. *Anti-centromere antibodies* - These antibodies are typically associated with CREST syndrome (a limited form of systemic sclerosis), characterized by Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. - This clinical picture does not align with the patient's symptoms, which point more towards an inflammatory multi-systemic disease. *Anti-RNP antibodies* - Anti-ribonucleoprotein (RNP) antibodies are characteristic of Mixed Connective Tissue Disease (MCTD) [2], which features overlapping symptoms of SLE, systemic sclerosis, and polymyositis [3]. - While some features like arthralgia might overlap, the classic erythematous lesions and breathlessness are more directly linked to SLE in this presentation, and anti-dsDNA is more specific for distinguishing SLE. *Anti-Scl 70 antibodies* - Also known as anti-topoisomerase I antibodies, these are highly specific for diffuse cutaneous systemic sclerosis. - This condition is characterized by widespread skin thickening, interstitial lung disease, and other visceral organ involvement, which is not fully supported by the patient's primary symptoms of prominent erythematous rashes and isolated arthralgia.

Question 632: Which of the following is not a first-line drug for the management of a patient with rheumatoid arthritis?

A. Hydroxychloroquine
B. Sulfasalazine
C. Azathioprine (Correct Answer)
D. Methotrexate

Explanation: ***Azathioprine*** - While an **immunosuppressant**, azathioprine is generally reserved for patients with **refractory rheumatoid arthritis (RA)** or those who cannot tolerate or have failed first-line DMARDs. - Its use often comes with a higher risk of side effects, making it less suitable as an initial agent compared to other conventional synthetic DMARDs. *Hydroxychloroquine* - This is a **first-line DMARD** for RA, particularly in patients with **mild disease**, due to its relatively favorable safety profile. - It is often used in combination with other DMARDs like methotrexate. *Sulfasalazine* - Sulfasalazine is a common **first-line conventional synthetic DMARD** for RA, especially effective in patients with peripheral arthritis. - It is frequently used when methotrexate is contraindicated or not tolerated, or as part of combination therapy. *Methotrexate* - **Methotrexate is considered the cornerstone** and **first-line treatment** for most patients with rheumatoid arthritis due to its efficacy and tolerability [1]. - It is recommended for early initiation in newly diagnosed patients to prevent joint damage and improve outcomes [2].

Question 633: A 35-year-old female presents with skin thickening and muscle weakness. Her peripheries became pale on exposure to cold. Her ANA is positive and creatine kinase is increased. Scl-70 is positive and perifascicular infiltration is noted in biopsy. What is the antibody associated with this condition?

A. Anti Jo1 antibody
B. Anti centromere antibody
C. Antinuclear antibody
D. Anti PM scl antibody (Correct Answer)

Explanation: ***Anti PM scl antibody*** - The constellation of **skin thickening** [2], **muscle weakness** [1], **Raynaud's phenomenon** (pale peripheries on cold exposure) [3], **elevated creatine kinase**, and **perifascicular infiltration** on muscle biopsy indicates an overlap syndrome between **systemic sclerosis** and **polymyositis/dermatomyositis** [3]. - **Anti-PM/Scl antibodies** are highly specific markers for this **overlap syndrome**, explaining the mixed features of scleroderma and myositis. *Anti Jo1 antibody* - This antibody is primarily associated with **polymyositis** or **dermatomyositis**, especially with the **anti-synthetase syndrome**, which includes features like **interstitial lung disease**, **Raynaud's**, and **arthritis** [1]. - While muscle weakness is present, the prominent skin thickening and positive Scl-70 point away from isolated myositis. *Anti centromere antibody* - This antibody is characteristic of **limited cutaneous systemic sclerosis (CREST syndrome)**, which involves **calcinosis**, **Raynaud's phenomenon**, esophageal dysmotility, sclerodactyly, and telangiectasias. - While Raynaud's is present, the widespread skin thickening, muscle weakness, and perifascicular infiltration are not typical of limited cutaneous systemic sclerosis. *Antinuclear antibody* - A **positive antinuclear antibody (ANA)** is a general screening test for **autoimmune diseases** and is present in a wide range of conditions, including systemic sclerosis, lupus, and myositis [4]. - While ANA is positive in this patient, it is not specific enough to diagnose the exact overlap syndrome with its unique clinical and laboratory findings.

Question 634: History of a woman with skin features like limited cutaneous systemic sclerosis (scleroderma) was given. What is the most specific marker?

A. Anti centromere (Correct Answer)
B. Anti U1 Rnp
C. Anti Jo
D. Anti La

Explanation: ***Anti centromere*** - **Anti-centromere antibodies** are highly specific for **limited cutaneous systemic sclerosis** (lcSSc), also known as CREST syndrome. - Their presence correlates with a higher risk of **pulmonary hypertension** and less severe organ involvement compared to diffuse SSc [1]. *Anti U1 Rnp* - **Anti-U1 RNP antibodies** are primarily associated with **mixed connective tissue disease** (MCTD) [2]. - While MCTD can have features overlapping with scleroderma, anti-U1 RNP is not the most specific marker for a pure scleroderma presentation. *Anti Jo* - **Anti-Jo-1 antibodies** are characteristic of **polymyositis** and **dermatomyositis**, diseases involving muscle inflammation [2]. - They are primarily associated with the **anti-synthetase syndrome**, which includes myositis, interstitial lung disease, and Raynaud's phenomenon, not directly limited cutaneous systemic sclerosis. *Anti La* - **Anti-La (SS-B) antibodies** are commonly found in patients with **Sjögren's syndrome**, an autoimmune disorder affecting moisture-producing glands [2]. - They can also be present in systemic lupus erythematosus, but are not specific for scleroderma.

Question 635: A 48-year-old female presents to your office with a 1-year history of dry eyes and difficulty swallowing. She complains of blinking frequently and of eye strain while using her computer at work. She also reports stiffness in her knees and lower back. Past medical history is unremarkable and she does not take medications. She denies cigarette or alcohol use. Family history is notable for Hashimoto's thyroiditis in her mother. Physical exam shows dry oral mucosa and enlargement of the parotid glands. Which of the following serologies is likely to be positive in this patient?

A. Anti-Jo-1
B. Anti-dsDNA
C. Anti-SS-A (Correct Answer)
D. Anti-Smith
E. Anti-CCP

Explanation: ***Anti-SS-A*** * This patient's symptoms of **dry eyes**, **difficulty swallowing**, **dry oral mucosa**, and **enlarged parotid glands** are highly indicative of **Sjögren's syndrome** [1]. * **Anti-SS-A (Ro)** antibodies are present in 60-70% of patients with primary Sjögren's syndrome and are recognized as a diagnostic marker [1]. * *Anti-Jo-1* * **Anti-Jo-1** antibodies are primarily associated with **polymyositis** and **dermatomyositis**, particularly the anti-synthetase syndrome, characterized by muscle weakness and interstitial lung disease, which are not described in this patient. * The patient's symptoms are focused on sicca manifestations rather than muscle inflammation. * *Anti-dsDNA* * **Anti-dsDNA** antibodies are highly specific for **Systemic Lupus Erythematosus (SLE)** and are often associated with lupus nephritis. * The patient presents with symptoms more consistent with a primary sicca disorder rather than the multi-systemic involvement typical of SLE. * *Anti-Smith* * **Anti-Smith** antibodies are also highly specific for **Systemic Lupus Erythematosus (SLE)**, though less sensitive than anti-dsDNA [1]. * These antibodies are not typically found in Sjögren's syndrome without co-existing SLE. * *Anti-CCP* * **Anti-CCP (cyclic citrullinated peptide)** antibodies are highly specific for **rheumatoid arthritis** [2]. * While the patient reports knee and lower back stiffness, the primary complaints and physical findings point towards Sjögren's syndrome, not inflammatory arthritis.

Question 636: A lady, when exposed to cold, experiences extremities turning blue. Which of the following antibodies is associated with this condition?

A. Anti-RO
B. Anti-SS-B
C. Anti-SS-A
D. Anti-SCL-70 (Correct Answer)

Explanation: Anti-SCL-70 - The symptom of extremities turning blue, especially upon cold exposure, describes **Raynaud's phenomenon**, a common feature of **systemic sclerosis (scleroderma)** [1]. - **Anti-SCL-70 antibodies** (topoisomerase 1 antibodies) are highly specific for **diffuse cutaneous systemic sclerosis**, a severe form of the disease often associated with Raynaud's. *Anti-RO* - **Anti-RO (SSA) antibodies** are primarily associated with **Sjögren's syndrome** and **subacute cutaneous lupus erythematosus**, conditions not typically characterized by prominent Raynaud's as the presenting symptom [2]. - While Sjögren's syndrome can have Raynaud's, it's not the defining feature and other symptoms like **dry eyes** and **dry mouth** would likely be present. *Anti-SS-B* - **Anti-SS-B (La) antibodies** are also associated with **Sjögren's syndrome**, often appearing alongside anti-RO antibodies [2]. - Their presence does not directly point to diffuse systemic sclerosis or severe Raynaud's as the primary condition. *Anti-SS-A* - **Anti-SS-A (RO) antibodies** are primarily linked to **Sjögren's syndrome** and **neonatal lupus**, and can also be seen in **systemic lupus erythematosus** [2]. - While Raynaud's can occur in lupus, the presence of isolated cold-induced blue extremities points more strongly towards systemic sclerosis given the provided options.

Question 637: Which of the following is the best investigation for acute gout?

A. Uric acid in urine
B. Anti CCP antibodies
C. Serum uric acid
D. Uric acid in synovial fluid (Correct Answer)

Explanation: ***Uric acid in synovial fluid*** - The definitive diagnosis of acute gout is established by identifying **negatively birefringent needle-shaped uric acid crystals** within the synovial fluid of the affected joint [1]. - This method directly confirms the presence of **monosodium urate crystals**, which are the hallmark of gout, offering diagnostic certainty [1]. *Uric acid in urine* - While urinary uric acid levels can help assess uric acid excretion, they are not diagnostic for acute gout and do not directly show the presence of **intra-articular crystals**. - This test is more relevant for investigating the **cause of hyperuricemia** (overproduction vs. underexcretion) rather than diagnosing an acute flare. *Anti CCP antibodies* - **Anti-cyclic citrullinated peptide (anti-CCP) antibodies** are markers for **rheumatoid arthritis** and are not relevant for the diagnosis of acute gout. - Their presence indicates an autoimmune inflammatory condition distinct from crystal-induced arthropathy. *Serum uric acid* - Serum uric acid levels are often elevated during an acute gout flare (**hyperuricemia**), but this is not diagnostic, as many individuals with hyperuricemia never develop gout [1]. - Approximately 30% of patients may have **normal serum uric acid levels** during an acute attack, making it an unreliable sole diagnostic criterion.

Question 638: Diagnosis of Gout is confirmed by which test?

A. X- ray changes
B. Urine uric acid levels
C. Synovial fluid analysis (Correct Answer)
D. Serum Uric acid level

Explanation: ***Synovial fluid analysis*** - Diagnosis of gout is definitively confirmed by the presence of **negatively birefringent, needle-shaped urate crystals** within neutrophils in the synovial fluid [1]. - This direct visualization of crystals confirms the diagnosis and differentiates gout from other forms of arthritis [1]. *X-ray changes* - While X-rays can show characteristic changes in chronic gout, such as **punched-out erosions with overhanging edges** (rat-bite erosions), these are not diagnostic of acute gout and may appear late in the disease course. - X-ray findings are less specific and do not confirm the presence of urate crystals. *Urine uric acid levels* - Urine uric acid levels help to distinguish between **overproducers and underexcreters** of uric acid, which can guide long-term management strategies [1]. - However, they do not directly confirm the diagnosis of an acute gouty attack. *Serum Uric acid level* - Elevated serum uric acid (hyperuricemia) is a prerequisite for gout, but many individuals with hyperuricemia never develop gout [1]. - Therefore, a **high serum uric acid level alone is not sufficient** to diagnose gout, especially during an acute attack when levels can sometimes be normal [1].

Question 639: Arthritis mutilans is seen in?

A. Psoriatic arthropathy (Correct Answer)
B. Reactive arthritis
C. Rheumatoid arthritis
D. Spondyloarthropathy

Explanation: ***Psoriatic arthropathy*** - **Arthritis mutilans** is a severe, destructive form of arthritis characterized by the **resorption of bone**, leading to **telescoping of digits** and severe deformities, most commonly seen in psoriatic arthritis [1]. - It affects approximately 5% of patients with psoriatic arthritis and is associated with significant functional impairment [1]. *Reactive arthritis* - Characterized by **asymmetric oligoarthritis** that typically follows a **genitourinary or gastrointestinal infection** [2]. - While it can cause joint inflammation, it is not associated with the severe bone resorption and telescoping deformities seen in arthritis mutilans [2]. *Rheumatoid arthritis* - Primarily affects the **small joints** of the hands and feet symmetrically, leading to inflammation, pannus formation, and joint destruction, but typically not **bone resorption** leading to telescoping [3]. - While significant joint deformities can occur (e.g., **swan-neck**, **boutonnière deformities**), these are distinct from the *pencil-in-cup* or telescoping appearance of arthritis mutilans [3]. *Spondyloarthropathy* - This is a broader category of inflammatory arthritides including **ankylosing spondylitis**, psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis [4]. - While **psoriatic arthropathy** is a type of spondyloarthropathy, the term itself is too general to specifically indicate arthritis mutilans.

Question 640: The primary goal of glucocorticoid treatment in rheumatoid arthritis is:

A. Prevention of suppression of the hypothalamic pituitary adrenal axis
B. Development of a sense of well-being in the patient
C. Suppression of inflammation and improvement in functional capacity (Correct Answer)
D. Reversal of the degenerative process

Explanation: ***Suppression of inflammation and improvement in functional capacity*** - **Glucocorticoids** are potent anti-inflammatory agents that rapidly reduce joint pain, swelling, and stiffness in **rheumatoid arthritis (RA)** [1]. - By controlling inflammation, they significantly improve the patient's **functional capacity** and quality of life, especially during flares or while waiting for disease-modifying antirheumatic drugs (DMARDs) to take effect [1]. *Prevention of suppression of the hypothalamic pituitary adrenal axis* - **Suppression of the hypothalamic-pituitary-adrenal (HPA) axis** is a potential adverse effect of glucocorticoid therapy, not a therapeutic goal. - This adverse effect is managed by careful dosing and tapering, not by the drug's primary action. *Development of a sense of well-being in the patient* - While patients often report an improved **sense of well-being** due to reduced pain and inflammation, this is a secondary effect of effective symptom control, not the primary therapeutic goal itself. - Glucocorticoids can also induce mood changes, including euphoria, which is a side effect rather than a targeted therapeutic outcome. *Reversal of the degenerative process* - Glucocorticoids can slow the progression of joint damage by suppressing inflammation, but they do **not reverse** established **degenerative processes** or structural damage in RA [2]. - **DMARDs** are the primary agents for preventing progressive joint destruction and maintaining long-term remission in RA [1].

Practice by Chapter

Rheumatoid Arthritis

Practice Questions

Spondyloarthropathies

Practice Questions

Systemic Lupus Erythematosus

Practice Questions

Vasculitis Syndromes

Practice Questions

Scleroderma and Related Disorders

Practice Questions

Inflammatory Myopathies

Practice Questions

Crystal Arthropathies

Practice Questions

Osteoarthritis

Practice Questions

Primary Immunodeficiency Disorders

Practice Questions

Autoinflammatory Syndromes

Practice Questions

Sjögren's Syndrome

Practice Questions

Antiphospholipid Syndrome

Practice Questions

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