Rheumatology and Immunology Practice Questions

Q: Which condition is characterized by the triad of skin lesions, mononeuritis multiplex, and elevated eosinophils?

Churg - Strauss syndrome. ***Churg - Strauss syndrome*** - **Churg-Strauss syndrome** (now known as **Eosinophilic Granulomatosis with Polyangiitis, EGPA**) is characterized by the triad of **skin lesions**, **mononeuritis multiplex** (nerve damage), and **elevated eosinophils** [1]. - It is a **small-vessel vasculitis** with a strong association with **asthma** and **allergic rhinitis** [1]. *Alports syndrome* - **Alport syndrome** is an inherited disorder affecting **type IV collagen**, primarily manifesting as **glomerulonephritis**, **sensorineural hearing loss**, and **ocular abnormalities**. - It does not present with skin lesions, mononeuritis multiplex, or eosinophilia. *Wegeners granulomatosus* - **Wegener's granulomatosis** (now **Granulomatosis with Polyangiitis, GPA**) is characterized by **granulomatous inflammation** of the upper and lower respiratory tracts, **glomerulonephritis**, and **systemic vasculitis** [2]. - While it can cause skin lesions and neuropathy, it is typically associated with **antineutrophil cytoplasmic antibodies (ANCAs)** and does not typically involve eosinophilia as a defining feature [1]. *Cryoglobulinemia* - **Cryoglobulinemia** is a condition where abnormal immunoglobulins (cryoglobulins) precipitate in cold temperatures, leading to **vasculitis-like symptoms** in small and medium-sized vessels. - It often manifests as **palpable purpura**, **arthralgia**, and **glomerulonephritis**, but mononeuritis multiplex and elevated eosinophils are not primary or defining features.

Q: Takayasu arteritis mainly affects?

Subclavian artery. ***Subclavian artery*** - **Takayasu arteritis** is a chronic inflammatory disorder that primarily affects the **aorta** and its **major branches**, including the subclavian arteries [1]. - Inflammation of the subclavian arteries can lead to **stenosis** or **occlusion**, resulting in symptoms such as **arm claudication**, **pulse deficit**, and blood pressure discrepancies between arms. *Pulmonary artery* - While Takayasu arteritis can, in rare cases, affect the pulmonary arteries, it is not their primary or most common target. - **Pulmonary artery involvement** is less frequent and generally seen in more widespread or severe disease. *Celiac artery* - The celiac artery, a branch of the aorta supplying the foregut, can be affected by **Takayasu arteritis**, but it is less commonly involved than the great vessels emanating from the aortic arch. - Involvement here can lead to symptoms like **abdominal pain** or **mesenteric ischemia**. *Aorta* - Takayasu arteritis primarily targets the **aorta** and its **proximal branches**, but "subclavian artery" is a more specific and common site of severe clinical manifestation often associated with the disease [1]. - The aorta itself is frequently affected, leading to **aneurysms**, **stenosis**, or **dilatation** throughout its course.

Q: In patients with the limited cutaneous form of CREST syndrome, which autoantibody is most commonly found?

Anti-centromere antibodies. ***Anti-centromere antibodies*** - **Anti-centromere antibodies (ACA)** are highly specific for the **limited cutaneous systemic sclerosis (lcSSc)**, often referred to as CREST syndrome. - They are associated with a milder course of the disease and a lower risk of serious internal organ involvement, especially **pulmonary fibrosis**. *Anti-DNA topoisomerase I* - **Anti-DNA topoisomerase I (Scl-70 antibodies)** are classically associated with the **diffuse cutaneous systemic sclerosis (dcSSc)**. - Patients with Scl-70 antibodies are at higher risk for **interstitial lung disease** and more generalized skin involvement. *Anti-double-stranded DNA antibodies* - **Anti-double-stranded DNA (anti-dsDNA) antibodies** are a hallmark of **systemic lupus erythematosus (SLE)**, not systemic sclerosis [1]. - Their presence often correlates with **lupus nephritis** and disease activity in SLE [1]. *Anti-Golgi antibodies* - **Anti-Golgi antibodies** are less commonly tested and are not specifically associated with systemic sclerosis or CREST syndrome. - They are sometimes found in various **autoimmune liver diseases** or in patients with certain neurological conditions.

Q: Anti Jo-1 antibodies are a feature associated with?

Polymyositis. Polymyositis - **Anti-Jo-1 antibodies** are a specific type of **anti-synthetase antibody** and are a key serological marker for polymyositis [1]. - Their presence often indicates a more severe form of the disease with a higher likelihood of **interstitial lung disease**, **Raynaud's phenomenon**, and **"mechanic's hands"** [1]. *Systemic sclerosis (scleroderma)* - While systemic sclerosis is also an **autoimmune connective tissue disease**, it is typically associated with antibodies such as **anti-Scl-70** (topoisomerase I) or **anti-centromere antibodies**. - **Anti-Jo-1 antibodies** are not characteristic of systemic sclerosis; their presence would suggest a different or overlapping diagnosis. *Rheumatoid arthritis (RA)* - **Rheumatoid arthritis** is primarily diagnosed by the presence of **rheumatoid factor (RF)** and **anti-cyclic citrullinated peptide (anti-CCP) antibodies**. - **Anti-Jo-1 antibodies** are not found in the typical serological profile of rheumatoid arthritis. *Systemic lupus erythematosus (SLE)* - **Systemic lupus erythematosus** is characterized by a wide array of autoantibodies, most notably **anti-nuclear antibodies (ANA)**, **anti-dsDNA antibodies**, and **anti-Sm antibodies** [2]. - **Anti-Jo-1 antibodies** are rarely, if ever, found in SLE and would point away from this diagnosis.

Q: Arthritis involving DIP, PIP, 1st carpometacarpal with sparing of MCP and wrist joints is typical of ?

Osteoarthritis. ***Osteoarthritis*** - **Osteoarthritis** characteristically affects the **DIP (Heberden's nodes)**, **PIP (Bouchard's nodes)**, and the **first carpometacarpal joint** at the base of the thumb [1]. - It typically spares the **MCP and wrist joints**, which helps differentiate it from inflammatory arthropathies like rheumatoid arthritis [1], [2]. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **MCP and wrist joints**, sparing the DIP joints [2]. - It presents with **symmetrical polyarthritis** and often includes systemic symptoms [2]. *Ankylosing spondylitis* - **Ankylosing spondylitis** primarily affects the **axial skeleton**, particularly the sacroiliac joints and spine. - While peripheral joint involvement can occur, it's typically in larger joints and not the characteristic DIP/PIP pattern of this case. *Psoriatic arthritis* - **Psoriatic arthritis** can affect the **DIP joints** and can present with patterns similar to osteoarthritis or rheumatoid arthritis [3]. - However, it's strongly associated with **psoriasis** (skin and nail changes) and can involve various other patterns, including **dactylitis** (sausage digits) and enthesitis, which makes it less typical for the described sparing pattern alone [3].

Q: Which joint is most commonly affected in pseudogout?

Knee. ***Knee*** - The **knee joint** is the most frequent site of acute attacks and chronic arthropathy in pseudogout due to the propensity for **calcium pyrophosphate dihydrate (CPPD)** crystal deposition in larger joints [1]. - Patients often present with acute, painful, and swollen knees, sometimes mimicking septic arthritis or gout [1]. *Hip* - While hip involvement can occur in pseudogout, it is **less common** than knee involvement and often manifests as chronic degenerative changes. - Acute hip flares are rarer compared to the knee. *MP joint great toe* - The **metatarsaophalangeal (MTP) joint of the great toe** is the classic site for **gout**, caused by monosodium urate crystal deposition. - Although pseudogout can affect various joints, this specific location is strongly indicative of gout, not pseudogout. *MP joint thumb* - The **metacarpophalangeal (MCP) joint of the thumb** can be affected in various arthropathies, but it is not the most commonly affected joint in pseudogout. - Involvement here is less specific for pseudogout compared to the knee.

Q: Which of the following is NOT a major criterion in the Modified Jones Criteria for diagnosing Rheumatic Fever?

Polyarthalgia. ***Polyarthralgia*** - **Polyarthralgia** is a **minor criterion** in the Modified Jones Criteria, indicating joint pain without objective signs of inflammation. - For a criterion to be considered major, it must involve objective signs of arthritis, which differentiate it from mere pain. [1] *Carditis* - **Carditis** is a **major criterion** and refers to inflammation of the heart, which can manifest as pericarditis, myocarditis, or endocarditis, often leading to valvular damage. [1] - It is one of the most serious manifestations of rheumatic fever and can lead to long-term cardiac complications. *Chorea* - **Sydenham chorea** (also known as St. Vitus' dance) is a **major criterion** characterized by involuntary, purposeless movements, primarily affecting the face, hands, and feet. [1] - It is a neurological manifestation reflecting central nervous system involvement and can appear late in the course of the disease. [1] *Erythema marginatum* - **Erythema marginatum** is a **major criterion** presenting as a distinctive, transient, non-pruritic rash with pink or red rings and clear centers, typically appearing on the trunk and proximal extremities. - This rash is a specific skin manifestation of acute rheumatic fever, though it is relatively uncommon.

Q: Tophi in gout are typically found in all regions except which of the following?

Muscle. ***Muscle*** - **Tophi** are crystalline deposits of **monosodium urate** that form in chronic gout [1]. They are typically found in cooler, less vascularized tissues, or tissues subjected to repetitive trauma. - While tophi can occur in many soft tissues, their presence **within muscle tissue is rare**, as muscle is well-vascularized and not a primary site for urate deposition [2]. *Prepatellar bursae* - The **prepatellar bursa** is a common site for tophi due to its superficial location and exposure to trauma. - Inflammation of the prepatellar bursa due to tophi accumulation is known as **"housemaid's knee"**. *Helix of ear* - The **helix of the ear** is a classic location for tophi due to its cooler temperature and poor vascularity, making it an ideal site for urate crystal deposition [1]. - These are often painless, subcutaneous nodules. *Synovial membrane* - The **synovial membrane** lining joints is a very common site for tophi formation, leading to destructive arthritis in chronic gout [2]. - Urate crystals in the synovial fluid provoke acute inflammatory attacks and can accumulate in the membrane over time.

Q: The most likely diagnosis in the case of a patient with multiple pulmonary cavities, hematuria, and red cell casts is?

Wegener's granulomatosis. ***Wegener's granulomatosis (Granulomatosis with Polyangiitis)*** - This condition classically presents with a **triad of upper airway, lower airway, and renal involvement** [1]. **Pulmonary cavities** represent severe lung involvement, and **hematuria with red cell casts** indicate rapidly progressive glomerulonephritis [3]. - It is an **ANCA-associated vasculitis**, specifically associated with **c-ANCA (anti-PR3 antibodies)**, and often leads to **granulomatous inflammation** [1], [3]. *Anti-GBM disease* - Characterized by **glomerulonephritis** and **pulmonary hemorrhage** (Goodpasture's syndrome) [1], but does not typically cause multiple **pulmonary cavities**. - Diagnosed by the presence of **anti-glomerular basement membrane antibodies** and linear IgG deposition on renal biopsy [1]. *Churg-Strauss* - This condition, now known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, is characterized by **asthma, eosinophilia, and vasculitis** [1]. - While it can affect the lungs and kidneys, **pulmonary cavities** are less common, and severe eosinophilia is a hallmark, which is not mentioned here [1]. *Systemic lupus erythematosus* - A multisystem autoimmune disease that can cause **glomerulonephritis (lupus nephritis)** and pleuropulmonary involvement [2]. - However, **multiple pulmonary cavities** are not a typical manifestation, and other classic lupus features (e.g., malar rash, arthralgias) are absent in the description [2].

Q: What is the most common variant of Takayasu Disease in India?

Type V. ***Type V*** - **Type V Takayasu arteritis** involves both the **aortic arch and its branches** (similar to Type I or II) AND the **abdominal aorta** and/or **renal arteries** (similar to Type III or IV) [1]. - This extensive involvement is the **most common presentation** of Takayasu arteritis in India, characterized by widespread vasculopathy affecting multiple arterial segments. *Type I* - **Type I Takayasu arteritis** primarily affects the **aortic arch** and its main branches, such as the subclavian, carotid, and vertebral arteries [1]. - While present in India, it is **less common** than Type V, which also includes abdominal aortic involvement. *Type III* - **Type III Takayasu arteritis** involves the **thoracic descending aorta, abdominal aorta**, and/or **renal arteries**, in addition to the **aortic arch branches**. - Although it includes abdominal involvement, it does not encompass the full range of involvement seen in the most prevalent Indian variant, Type V. *Type IV* - **Type IV Takayasu arteritis** is characterized by involvement of the **abdominal aorta** and/or **renal arteries** [1]. - This type is less common as a sole presentation in India; typically, renal artery involvement is part of a more generalized arterial inflammation, as seen in Type V.

Question 1

Which condition is characterized by the triad of skin lesions, mononeuritis multiplex, and elevated eosinophils?

Accepted Answer

Churg - Strauss syndrome

Answer

Alports syndrome

Answer

Wegeners granulomatosus

Answer

Cryoglobulinemia

Question 2

Takayasu arteritis mainly affects?

Accepted Answer

Subclavian artery

Answer

Pulmonary artery

Answer

Celiac artery

Answer

Aorta

Question 3

In patients with the limited cutaneous form of CREST syndrome, which autoantibody is most commonly found?

Accepted Answer

Anti-centromere antibodies

Answer

Anti-DNA topoisomerase I

Answer

Anti-double-stranded DNA antibodies

Answer

Anti-Golgi antibodies

Question 4

Anti Jo-1 antibodies are a feature associated with?

Accepted Answer

Polymyositis

Answer

Systemic sclerosis (scleroderma)

Answer

Rheumatoid arthritis (RA)

Answer

Systemic lupus erythematosus (SLE)

Question 5

Arthritis involving DIP, PIP, 1st carpometacarpal with sparing of MCP and wrist joints is typical of ?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Question 6

Which joint is most commonly affected in pseudogout?

Accepted Answer

Knee

Answer

Hip

Answer

MP joint great toe

Answer

MP joint thumb

Question 7

Which of the following is NOT a major criterion in the Modified Jones Criteria for diagnosing Rheumatic Fever?

Accepted Answer

Polyarthalgia

Answer

Erythema marginatum

Answer

Carditis

Answer

Chorea

Question 8

Tophi in gout are typically found in all regions except which of the following?

Accepted Answer

Muscle

Answer

Helix of ear

Answer

Prepatellar bursae

Answer

Synovial membrane

Question 9

The most likely diagnosis in the case of a patient with multiple pulmonary cavities, hematuria, and red cell casts is?

Accepted Answer

Wegener's granulomatosis

Answer

Anti-GBM disease

Answer

Churg-Strauss

Answer

Systemic lupus erythematousus

Question 10

What is the most common variant of Takayasu Disease in India?

Accepted Answer

Type V

Answer

Type III

Answer

Type IV

Answer

Type I

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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