Rheumatology and Immunology Practice Questions

Q: A 35-year-old female with heliotrope rash and Gottron's papules has a muscle biopsy showing inflammatory myopathy. What is the diagnosis?

Dermatomyositis. ***Dermatomyositis*** - The combination of a **heliotrope rash**, **Gottron's papules**, and **inflammatory myopathy** on muscle biopsy is pathognomonic for dermatomyositis [1], [2]. - This condition is characterized by **proximal muscle weakness** and distinctive dermatological manifestations [1], [2]. *Systemic lupus erythematosus (SLE)* - While SLE can cause a rash and myositis, the specific presentation of a **heliotrope rash** and **Gottron's papules** is not characteristic of SLE [2]. - SLE rashes typically include a **malar rash** or discoid lesions, and myositis is less common and usually milder [3]. *Polymyositis* - Polymyositis also presents with **inflammatory myopathy** and proximal muscle weakness, but it lacks the characteristic dermatological features seen in this patient [1]. - It does not involve **heliotrope rash** or **Gottron's papules** [1]. *Systemic sclerosis (SSc)* - SSc primarily affects the **skin** with thickening and hardening, and can involve internal organs, but does not typically present with the specific rash and papules described. - Muscle involvement in SSc is usually secondary to **fibrosis** or vasculopathy, distinct from the inflammatory myopathy of dermatomyositis.

Q: Ankylosing spondylitis most commonly affects which region of the spine?

Sacroiliac joints. ***Sacroiliac joints*** - Ankylosing spondylitis characteristically begins with inflammation of the **sacroiliac joints**, leading to **sacroiliitis** [1]. - This involvement is often **bilateral** and symmetrical, serving as a hallmark feature for diagnosis. *Cervical spine* - While the cervical spine can eventually be affected in later stages of ankylosing spondylitis, it is typically **not the initial or most common site** of involvement. - Involvement here can lead to neck stiffness and reduced range of motion, but usually **after** sacroiliac and lumbar spine disease. *Thoracic spine* - The thoracic spine may become involved in the progression of ankylosing spondylitis, contributing to the characteristic **"bamboo spine"** appearance. - However, it is **less commonly the primary site** of disease onset compared to the sacroiliac joints. *Lumbar spine* - The lumbar spine is frequently affected **after the sacroiliac joints**, leading to inflammation, stiffness, and eventual fusion [1]. - However, the **sacroiliiac joints are almost universally involved first** or concurrently, making them the most common initial presentation.

Q: A 54-year-old woman presents with proximal muscle weakness and a skin rash over her knuckles. Laboratory tests show elevated muscle enzymes and a positive anti-Jo-1 antibody. What is the most likely diagnosis?

Dermatomyositis. Dermatomyositis - The classic triad of **proximal muscle weakness**, a characteristic **skin rash over the knuckles** (Gottron's papules), and **elevated muscle enzymes** strongly indicates dermatomyositis [1]. - The presence of **anti-Jo-1 antibody** further supports the diagnosis, as this is an autoantibody specifically associated with dermatomyositis and polymyositis, particularly with interstitial lung disease [1, 2]. *Rheumatoid arthritis* - Primarily characterized by **symmetric polyarthritis** affecting small joints, not proximal muscle weakness. - While elevated inflammatory markers can be present, **muscle enzymes are typically normal**, and the rash over the knuckles is not typical [2]. *Systemic lupus erythematosus* - Can cause a wide range of symptoms including muscle pain and skin rashes (e.g., malar rash), but **proximal muscle weakness with elevated muscle enzymes** is not its primary presentation. - Specific autoantibodies like **anti-dsDNA** or **anti-Sm** are characteristic, rather than anti-Jo-1 [2]. *Scleroderma* - Characterized by **skin thickening** and **fibrosis of internal organs**, which are not described in this patient [3]. - While muscle involvement can occur, it's typically not the predominant feature, and the specific rash and anti-Jo-1 antibody are not indicative of scleroderma.

Q: A 60-year-old woman with rheumatoid arthritis presents with severe pain and swelling in her right knee. Arthrocentesis reveals cloudy fluid with a high white blood cell count. What is the most likely diagnosis?

Septic arthritis. ***Septic arthritis*** - The combination of **rheumatoid arthritis (RA)**, a severe inflammatory condition, with acute **monoarticular pain and swelling**, along with **cloudy synovial fluid** and a **high WBC count on arthrocentesis**, strongly suggests septic arthritis [1]. - Patients with RA are at **increased risk for septic arthritis** due to compromised immune systems from the disease itself and immunosuppressive medications [3]. *Gout* - While gout presents with acute inflammatory arthritis, it typically involves **negatively birefringent, needle-shaped crystals** of **monosodium urate** in the synovial fluid. - The synovial fluid in this case is described as cloudy with a high WBC count, requiring further crystal analysis to confirm gout, but **infection is a more pressing concern** given the RA history. *Pseudogout* - Pseudogout, caused by **calcium pyrophosphate dihydrate (CPPD) crystals**, would show **positively birefringent, rhomboid-shaped crystals** in the synovial fluid [2]. - Like gout, it is an inflammatory arthritis, but the primary concern with a high WBC count and RA history is ruling out bacterial infection. *Osteoarthritis* - Osteoarthritis typically causes **chronic, progressive joint pain** and is associated with **clear to mildly cloudy synovial fluid** with a **low WBC count** (<2000 cells/mm³). - The acute, severe symptoms and high WBC count are inconsistent with uncomplicated osteoarthritis [2].

Q: The patient is presenting with the deformity of the finger as shown. The PIP is involved but the DIP is spared

Rheumatoid arthritis. ***Rheumatoid arthritis*** - The image shows a **Boutonniere deformity**, characterized by **flexion of the PIP joint** and hyperextension of the DIP joint, which is classic for rheumatoid arthritis. - **Rheumatoid arthritis** typically affects the small joints of the hands and feet, particularly the **PIP joints and MCP joints**, sparing the DIP joints. *Osteoarthritis* - Osteoarthritis commonly involves the **DIP joints (Heberden's nodes)** and **PIP joints (Bouchard's nodes)**, but the depicted deformity (Boutonniere) is not typical. - It is primarily a degenerative joint disease, not inflammatory, and tends to spare the MCP joints until very late in the disease. *Psoriatic Arthritis* - Psoriatic arthritis often involves the **DIP joints and causes dactylitis (sausage digits)**, which is not clearly depicted, although Boutonniere can occur. - The key differentiator is usually the presence of **psoriasis skin lesions or nail changes**, which are not mentioned or visible in the image. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton**, particularly the **sacroiliac joints** and spine, leading to stiffness and pain. - While peripheral joint involvement can occur, it is generally not characterized by specific hand deformities like Boutonniere deformity.

Q: Which of the following is NOT a typical feature of seropositive rheumatoid arthritis?

Asymmetrical joint involvement. ***Asymmetrical joint involvement*** - **Seropositive rheumatoid arthritis** typically presents with **symmetrical polyarthritis**, meaning that joints on both sides of the body are affected similarly [1]. - While some asymmetry can occur in early stages or with atypical presentations, it is not considered a **typical feature** of established rheumatoid arthritis [1]. *Inflammation in multiple joints* - **Polyarthritis**, or inflammation in multiple joints, is a hallmark of rheumatoid arthritis, distinguishing it from **mono-** or **oligoarthritis** [1], [2]. - This widespread involvement contributes to the systemic nature and disability associated with the disease. *Symmetrical joint involvement* - **Symmetry** in joint involvement is a classic and highly characteristic feature of rheumatoid arthritis, often affecting the same joints on both sides of the body [1]. - This symmetrical pattern helps differentiate rheumatoid arthritis from other forms of **inflammatory arthritis** that tend to be unilateral or asymmetrical [1]. *Joint pain and swelling* - **Joint pain** and **swelling** are among the most common and typical symptoms of active rheumatoid arthritis, reflecting the underlying inflammatory process [1]. - These symptoms are often accompanied by **morning stiffness** lasting more than 30 minutes, which resolves with activity [1].

Q: Which of the following is NOT a feature of inflammatory arthritis?

X-ray showing sclerosis. ***X-ray showing sclerosis*** - While an X-ray might show changes like **erosions** or **joint space narrowing** in inflammatory arthritis, prominent **sclerosis** is more characteristic of **osteoarthritis** or degenerative changes, not inflammation. - Inflammatory arthritis typically leads to **bone erosion** and **osteopenia** in the affected joints due to chronic inflammation. *Morning stiffness* - This is a hallmark symptom of **inflammatory arthritis**, usually lasting for more than 30 minutes to an hour. - It reflects the accumulation of inflammatory mediators in the joint space overnight. *Elevated ESR* - **Erythrocyte Sedimentation Rate (ESR)** is a common laboratory marker of **inflammation** and is often elevated in inflammatory arthritides. - An elevated ESR indicates increased levels of acute-phase reactants in the blood, which are part of the inflammatory response. *Weight gain* - **Weight gain** is generally not a direct feature of active inflammatory arthritis; rather, patients with active inflammation often experience **weight loss** due to the catabolic effects of inflammation. - However, inactivity secondary to joint pain or side effects of certain medications (e.g., corticosteroids) can contribute to weight gain in chronic cases.

Q: Psoriatic arthritis most commonly involves which joint -

Distal interphalangeal joint. ***Distal interphalangeal joint*** - Psoriatic arthritis has a predilection for the **distal interphalangeal (DIP) joints**, a feature that helps distinguish it from other inflammatory arthropathies. - Involvement of the DIP joints often correlates with **nail psoriasis** and can lead to characteristic **"sausage digits"** (dactylitis). *Proximal interphalangeal joint* - While **proximal interphalangeal (PIP) joints** can be affected in psoriatic arthritis, it is not the most common or characteristic pattern of involvement. - PIP joint involvement is more typically associated with **rheumatoid arthritis**, although it can occur in a polyarticular presentation of psoriatic arthritis. *Wrist joint* - The **wrist joint** can be affected in psoriatic arthritis, particularly in more severe or polyarticular forms, but it is not the most common initial presentation. - Wrist involvement can lead to significant pain and functional impairment but is less specific to psoriatic arthritis compared to DIP joint involvement. *Metacarpophalangeal joint* - **Metacarpophalangeal (MCP) joints** are also less commonly affected as the primary site in psoriatic arthritis compared to the DIP joints. - MCP joint involvement is a hallmark of **rheumatoid arthritis**, where it often presents with symmetrical inflammation.

Question 1

A 45-year-old patient presents with skin thickening, Raynaud's phenomenon, and digital ulcers. Which enzyme is the target of autoantibodies in this autoimmune disorder?

Accepted Answer

Histone deacetylase

Answer

DNA polymerase

Answer

Protein kinase

Answer

RNA polymerase II

Question 2

A 35-year-old female with heliotrope rash and Gottron's papules has a muscle biopsy showing inflammatory myopathy. What is the diagnosis?

Accepted Answer

Dermatomyositis

Answer

Systemic lupus erythematosus (SLE)

Answer

Polymyositis

Answer

Systemic sclerosis (SSc)

Question 3

Ankylosing spondylitis most commonly affects which region of the spine?

Accepted Answer

Sacroiliac joints

Answer

Cervical spine

Answer

Thoracic spine

Answer

Lumbar spine

Question 4

A 54-year-old woman presents with proximal muscle weakness and a skin rash over her knuckles. Laboratory tests show elevated muscle enzymes and a positive anti-Jo-1 antibody. What is the most likely diagnosis?

Accepted Answer

Dermatomyositis

Answer

Rheumatoid arthritis

Answer

Systemic lupus erythematosus

Answer

Scleroderma

Question 5

A 60-year-old woman with rheumatoid arthritis presents with severe pain and swelling in her right knee. Arthrocentesis reveals cloudy fluid with a high white blood cell count. What is the most likely diagnosis?

Accepted Answer

Septic arthritis

Answer

Gout

Answer

Pseudogout

Answer

Osteoarthritis

Question 6

The patient is presenting with the deformity of the finger as shown. The PIP is involved but the DIP is spared

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Psoriatic Arthritis

Answer

Ankylosing spondylitis

Question 7

Which of the following is NOT a typical feature of seropositive rheumatoid arthritis?

Accepted Answer

Asymmetrical joint involvement

Answer

Inflammation in multiple joints

Answer

Symmetrical joint involvement

Answer

Joint pain and swelling

Question 8

Which of the following is NOT a feature of inflammatory arthritis?

Accepted Answer

X-ray showing sclerosis

Answer

Morning stiffness

Answer

Elevated ESR

Answer

Weight gain

Question 9

All are true about Marie-Strumpell disease except which of the following?

Accepted Answer

Roentgenogram is the most sensitive investigation for Marie-Strumpell disease.

Answer

Enhesitis is common

Answer

Most commonly involves the sacro - iliac joints

Answer

More common in males

Question 10

Psoriatic arthritis most commonly involves which joint -

Accepted Answer

Distal interphalangeal joint

Answer

Proximal interphalangeal joint

Answer

Wrist joint

Answer

Metacarpophalangeal joint

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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