Rheumatology and Immunology — MCQs
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Which is associated with vasculitis of medium sized vessels
According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:
A 22-year-old man develops the insidious onset of low back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. Which test or group of tests would be most supportive of your suspected diagnosis?
A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis is
A young girl is admitted with joint pains and butterfly rash and positive urine proteinuria. The best test for her diagnosis is ?
False about Reactive arthritis
Most sensitive test for screening of SLE is
Anti ds DNA is most specific for:
All the following diseases are associated with HLA B-27 & Uveitis, except -
HLA typing is useful in:
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 641: Which is associated with vasculitis of medium sized vessels
- A. Wegener's granulomatosis
- B. Temporal arteritis
- C. Polyarteritis nodosa (Correct Answer)
- D. Henoch-Schönlein purpura
Explanation: ***Polyarteritis nodosa*** - **Polyarteritis nodosa (PAN)** is a **necrotizing vasculitis** of **medium-sized or small arteries**, but not arterioles, capillaries, or venules [1]. - It classically affects the **renal and visceral arteries**, sparing the pulmonary circulation, and is associated with **aneurysms** and stenoses. *Temporal arteritis* - This is a form of **large-vessel vasculitis** primarily affecting the **temporal and other cranial arteries** [1]. - It is typically seen in older adults and can cause **headache**, **jaw claudication**, and **blindness**. *Wegener's granulomatosis* - Now known as **Granulomatosis with Polyangiitis (GPA)**, this vasculitis affects **small vessels** and is characterized by a **granulomatous inflammation** of the upper and lower respiratory tracts and kidneys [1]. - It is associated with **PR3-ANCA (c-ANCA)** positivity. *Henoch-Schönlein purpura* - This is an **IgA vasculitis** affecting **small vessels**, typically presenting with **palpable purpura**, arthritis, abdominal pain, and renal involvement (nephritis) [1]. - It is the most common form of vasculitis in children.
Question 642: According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:
- A. Lack of warmth
- B. Crepitus
- C. Atrophy of quadriceps muscles (Correct Answer)
- D. Age > 50 years
Explanation: ### Atrophy of quadriceps muscles - While muscle weakness can be a consequence of **osteoarthritis (OA)** due to pain and disuse, **quadriceps atrophy** is not a primary diagnostic criterion according to the American College of Rheumatology (ACR) criteria for OA. Local examination of the knee in OA may frequently reveal weakness and wasting of the quadriceps muscle [1]. - The ACR criteria primarily focus on patient symptoms, physical exam findings, and radiographic evidence to define OA. ### Lack of warmth - This is a typical physical finding in osteoarthritis, as **inflammation** is generally mild or absent compared to inflammatory arthropathies, thus joints are usually **not warm** to the touch. - It helps differentiate OA from conditions like septic arthritis or gout, where warmth is a prominent feature. ### Crepitus - **Crepitus**, or crackling/grating sounds during joint movement, is a classic clinical finding in osteoarthritis, indicating a roughened articular surface. Examination often reveals restricted flexion/extension accompanied by coarse crepitus [1]. - It is one of the key clinical signs used in the ACR criteria for OA, especially when combined with other symptoms like pain and stiffness. ### Age > 50 years - **Age over 50 years** is a significant risk factor and a clinical criterion for diagnosing osteoarthritis, as the prevalence of OA increases with age. While typical symptoms usually present after age 45-50, early-onset OA is rare and often linked to trauma [1]. - The ACR criteria often incorporate age as a factor when considering symptomatic OA.
Question 643: A 22-year-old man develops the insidious onset of low back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. Which test or group of tests would be most supportive of your suspected diagnosis?
- A. An elevated sedimentation rate, a mild anemia on CBC, positive HLA-B27 in blood and sclerosis of the sacroiliac joints on plain films of the back. (Correct Answer)
- B. Lumbosacral x-rays showing vertebral joint space narrowing and osteophyte formation at various levels.
- C. A positive rheumatoid factor, anti-CCP, and an elevated C-reactive protein level.
- D. MRI of the lumbosacral spine showing spinal compression fractures associated with bony destruction.
Explanation: **An elevated sedimentation rate, a mild anemia on CBC, positive HLA-B27 in blood and sclerosis of the sacroiliac joints on plain films of the back.** - This constellation of findings is highly characteristic of **ankylosing spondylitis (AS)**, a seronegative spondyloarthropathy [1]. The patient's symptoms (insidious low back pain improving with exercise, worsened by rest, loss of lumbar mobility, kyphotic posture) are classic for AS [1]. - **HLA-B27** positivity is strongly associated with AS, and **sacroiliitis** (sclerosis of the sacroiliac joints) seen on imaging is a hallmark diagnostic feature [1]. **Elevated ESR** and **mild anemia** are common non-specific inflammatory markers seen in active AS. *Lumbosacral x-rays showing vertebral joint space narrowing and osteophyte formation at various levels.* - These findings are more indicative of **degenerative disc disease** or **osteoarthritis of the spine**, which typically worsens with activity and improves with rest, unlike the patient's symptoms [2]. - While common in older individuals, they do not explain the progressive inflammatory symptoms and characteristic posture of ankylosing spondylitis. *A positive rheumatoid factor, anti-CCP, and an elevated C-reactive protein level.* - **Positive rheumatoid factor (RF)** and **anti-CCP antibodies** are characteristic of **rheumatoid arthritis (RA)**, which primarily affects peripheral joints and is less commonly associated with the axial skeleton in this specific pattern. - Although **elevated CRP** indicates inflammation, RF and anti-CCP are not typically found in ankylosing spondylitis, hence why it's categorized as a **seronegative spondyloarthropathy** [1]. *MRI of the lumbosacral spine showing spinal compression fractures associated with bony destruction.* - **Spinal compression fractures with bony destruction** suggest conditions like metastatic cancer, severe osteoporosis, or severe infection (e.g., osteomyelitis), none of which align with the patient's insidious onset of inflammatory back pain and chronic progressive symptoms. - These findings are acute and destructive, unlike the chronic inflammatory and structural changes seen in ankylosing spondylitis.
Question 644: A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis is
- A. Rheumatoid factor
- B. Antinuclear antibody (Correct Answer)
- C. BUN and creatinine
- D. ECG
Explanation: ***Antinuclear antibody*** - The symptoms (Raynaud's phenomenon, arthralgias, dysphagia) are highly suggestive of a **systemic autoimmune disease**, such as **scleroderma** or **mixed connective tissue disease** [1], [2]. - An elevated **ANA** is a screening test for most autoimmune connective tissue diseases [1]; further specific autoantibodies (e.g., anti-centromere, anti-Scl-70) would then be ordered to confirm the specific diagnosis. *Rheumatoid factor* - While positive in **rheumatoid arthritis**, the patient's symptoms (Raynaud's, dysphagia) are less typical for RA and more indicative of other connective tissue disorders [1]. - A positive RF alone would not definitively diagnose the underlying systemic condition suggested by the symptom complex. *BUN and creatinine* - These tests assess **kidney function** and would be abnormal in cases of **renal involvement** due to autoimmune disease [1]. - While important for monitoring disease progression and complications, they are not a primary diagnostic test for the initial diagnosis of a systemic autoimmune condition. *ECG* - An **ECG** evaluates **cardiac electrical activity** and can detect arrhythmias or signs of ischemia. - While systemic autoimmune diseases can affect the heart, an ECG is not a screening or diagnostic test for the underlying autoimmune condition itself.
Question 645: A young girl is admitted with joint pains and butterfly rash and positive urine proteinuria. The best test for her diagnosis is ?
- A. Antibodies to RNP
- B. Antibodies to tRNA synthetase
- C. Anti ds-DNA antibody (Correct Answer)
- D. Anti-centromere antibody
Explanation: ***Anti ds-DNA antibody*** - The presence of **joint pains**, a **butterfly rash** (malar rash), and **proteinuria** are classic clinical features highly suggestive of **Systemic Lupus Erythematosus (SLE)** [1]. - **Anti-dsDNA antibodies** are highly specific for SLE and correlate well with disease activity, especially **lupus nephritis**, which is indicated by proteinuria [4]. *Antibodies to RNP* - **Anti-RNP antibodies** are associated with **Mixed Connective Tissue Disease (MCTD)** and can be present in SLE, but they are not as specific for SLE or its renal involvement as anti-dsDNA [2]. - While MCTD can have overlapping features with SLE [3], the combination of a butterfly rash and significant proteinuria steers the diagnosis more directly towards SLE. *Antibodies to tRNA synthetase* - **Anti-tRNA synthetase antibodies** (e.g., anti-Jo-1) are characteristic of **inflammatory myopathies** such as polymyositis and dermatomyositis, not SLE. - These antibodies are typically associated with muscle weakness, interstitial lung disease, and "mechanic's hands," which are not described in the patient's presentation. *Anti-centromere antibody* - **Anti-centromere antibodies** are highly specific for **Limited Cutaneous Systemic Sclerosis (CREST syndrome)** [2]. - CREST syndrome presents with calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias, which are not mentioned in this patient's symptoms.
Question 646: False about Reactive arthritis
- A. Enthesitis of Achilles tendon
- B. Precipitated by chlamydia
- C. Acute purulent arthritis (Correct Answer)
- D. Indomethacin is the initial treatment of choice
Explanation: ***Acute purulent arthritis*** - Reactive arthritis is a **sterile inflammatory arthritis**, meaning there is no bacterial infection in the joint fluid. - **Purulent arthritis** indicates a bacterial infection within the joint, which is not characteristic of reactive arthritis. *Enthesitis of Achilles tendon* - **Enthesitis**, particularly involving the Achilles tendon, is a common feature of **spondyloarthropathies**, including reactive arthritis [1]. - It refers to inflammation at the insertion sites of tendons, ligaments, or joint capsules into bone [1]. *Precipitated by chlamydia* - Reactive arthritis is frequently triggered by **genitourinary infections**, such as those caused by *Chlamydia trachomatis* [1]. - It falls under the category of **post-infectious arthritis**, where the infection precedes the joint symptoms [1]. *Indomethacin is the initial treatment of choice* - **Nonsteroidal anti-inflammatory drugs (NSAIDs)**, such as indomethacin, are the **first-line treatment** for managing pain and inflammation in reactive arthritis. - They help reduce joint pain, stiffness, and swelling, providing symptomatic relief.
Question 647: Most sensitive test for screening of SLE is
- A. Rheumatoid factor test
- B. Double-stranded DNA test
- C. Anti-nuclear antibody (Correct Answer)
- D. LE cell phenomenon
Explanation: ***Anti-nuclear antibody*** - An **ANA test** is highly sensitive for **Systemic Lupus Erythematosus (SLE)**, meaning a negative result makes SLE highly unlikely [1]. - While not specific for SLE, a positive ANA serves as an excellent **screening tool** to prompt further, more specific testing. *Rheumatoid factor test* - This test is primarily used for **Rheumatoid Arthritis** and is not a sensitive or specific marker for SLE [1]. - While it can be positive in some SLE patients, its utility as a primary screening test for SLE is limited compared to ANA. *Double-stranded DNA test* - **Anti-dsDNA antibodies** are highly specific for SLE and often correlate with disease activity, especially **lupus nephritis**. - However, they are **not as sensitive as ANA** for initial screening, meaning some SLE patients might have a negative anti-dsDNA test but still have the disease. *LE cell phenomenon* - The **LE cell phenomenon** is an older, less sensitive, and less specific test for SLE that has largely been replaced by modern serologic tests. - Its detection involves observing neutrophils engulfing nuclear material, but it is **technically challenging** and prone to false negatives and positives.
Question 648: Anti ds DNA is most specific for:
- A. SLE (Correct Answer)
- B. Polymyositis
- C. Scleroderma
- D. Rheumatoid arthritis
Explanation: ***SLE*** - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are often associated with **lupus nephritis** and disease activity [1]. - Their presence, along with clinical criteria, helps in confirming the diagnosis of SLE. *Polymyositis* - Polymyositis is characterized by **proximal muscle weakness** and elevated muscle enzymes, but not primarily by anti-dsDNA antibodies [1]. - Key autoantibodies in polymyositis include **anti-Jo-1** and other myositis-specific antibodies. *Scleroderma* - **Scleroderma (Systemic Sclerosis)** is characterized by skin thickening and internal organ fibrosis, with autoantibodies like **anti-Scl-70** and **anti-centromere antibodies** [1]. - **Anti-dsDNA antibodies** are not typically found in scleroderma. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** is a chronic inflammatory disorder primarily affecting the joints, and its characteristic autoantibodies are **rheumatoid factor (RF)** and **anti-citrullinated peptide antibodies (ACPA)**. - **Anti-dsDNA antibodies** are not relevant to the diagnosis of rheumatoid arthritis [1].
Question 649: All the following diseases are associated with HLA B-27 & Uveitis, except -
- A. Ankylosing Spondylitis
- B. Psoriasis
- C. Reiter's syndrome
- D. Behçet's syndrome (Correct Answer)
Explanation: **Behçet's syndrome** - **Behçet's syndrome** is an immune-mediated vasculitis characterized by recurrent oral and genital ulcers, skin lesions, and **uveitis**. It is strongly associated with **HLA-B51**, not HLA-B27. - While it can cause uveitis, its genetic association and clinical presentation are distinct from the HLA-B27 spondyloarthropathies. *Ankylosing Spondylitis* - **Ankylosing Spondylitis** is a chronic inflammatory disease primarily affecting the axial skeleton, characterized by sacroiliitis and spondylitis. It is strongly associated with **HLA-B27** and can present with **anterior uveitis** [1]. - Approximately 25-40% of patients with ankylosing spondylitis experience acute anterior uveitis, making it a common extra-articular manifestation. *Psoriasis* - **Psoriasis** is a chronic inflammatory skin condition that can be associated with **psoriatic arthritis**, a spondyloarthropathy [1]. Psoriatic arthritis has a genetic predisposition, with some cases linked to **HLA-B27**, and can manifest with **uveitis**. - The presence of uveitis in a patient with psoriasis and joint pain suggests psoriatic arthritis, a disease known to be associated with HLA-B27 in a subset of patients. *Reiter's syndrome* - **Reiter's syndrome**, now more commonly referred to as **Reactive Arthritis**, is a seronegative spondyloarthropathy that typically develops after a genitourinary or gastrointestinal infection. It is strongly associated with **HLA-B27** [1]. - The classic triad of symptoms includes **arthritis**, **urethritis**, and **conjunctivitis** or **uveitis**, making it a clear association with both HLA-B27 and uveitis [2].
Question 650: HLA typing is useful in:
- A. Disputed paternity
- B. Dactylography
- C. Organ transplant (Correct Answer)
- D. Thanatology
Explanation: ***Organ transplant*** - **HLA typing** is crucial for **matching donors and recipients** in organ transplantation to minimize the risk of transplant rejection [1]. - A better **HLA match** between donor and recipient reduces the likelihood of the recipient's immune system attacking the transplanted organ [1]. *Disputed paternity* - While **HLA typing** was historically used, **DNA fingerprinting** (using STR markers) is now the primary and more accurate method for determining paternity [2]. - **DNA analysis** provides a higher probability of inclusion or exclusion and is less complex to interpret than HLA typing for paternity [2]. *Dactylography* - **Dactylography** refers to the study of fingerprints for **identification purposes**, a field entirely unrelated to genetic markers. - It involves analyzing the unique patterns of **ridges and valleys** on fingertips, not genetic typing. *Thanatology* - **Thanatology** is the scientific study of **death and dying**, including the psychological, social, and cultural aspects. - It does not involve genetic testing like **HLA typing** but rather focuses on end-of-life care, grief, and the processes surrounding death.
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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