Rheumatology and Immunology — MCQs

45-year-old man presented to outpatient department with hot, swollen left big toe and a painful lesion on the rim of his left pinna. Polarized light microscopy of the synovial fluid shows dense neutrophilic infiltrate and crystals that are negatively birefringent. Patient is likely to be suffering from?

Q718

A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -

Q719

A 65-year-old man with history of back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in vertebrae. Diagnosis is -

Q720

Based on 1990 ACR criteria, the diagnosis of fibromyalgia is made in patients with a history of diffuse musculoskeletal pain and which of the following physical findings:

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 711: All are features of seronegative spondyloarthropathies except -

A. RA factor positive (Correct Answer)
B. Uveitis
C. Occur in young age
D. HLA-B27 positive

Explanation: ***RA factor positive*** - Seronegative spondyloarthropathies are specifically defined by the **absence of rheumatoid factor (RF)** in the blood. - Therefore, a positive RA factor would exclude a diagnosis of seronegative spondyloarthropathy. *Uveitis* - **Uveitis**, particularly **anterior uveitis**, is a common extra-articular manifestation of several seronegative spondyloarthropathies, such as ankylosing spondylitis and reactive arthritis [1]. - Its presence is a characteristic feature, not an exclusion criterion. *Occur in young age* - Seronegative spondyloarthropathies, such as **ankylosing spondylitis** and **reactive arthritis**, typically present in younger individuals, often before the age of 40. - This is a distinguishing feature compared to other arthropathies that might manifest later in life. *HLA-B27 positive* - **HLA-B27 positivity** is a strong genetic association with many seronegative spondyloarthropathies, particularly ankylosing spondylitis and reactive arthritis [1]. - While not universally present in all cases, it is a hallmark feature that aids in diagnosis [2].

Question 712: Windswept deformity of the knee is seen in -

A. Osteoarthritis
B. Ankylosing Spondylitis
C. Rheumatoid arthritis (Correct Answer)
D. Psoriatic arthritis

Explanation: **Rheumatoid arthritis** - **Windswept deformity** (valgus deformity in one knee and varus deformity in the other) is a classic finding in advanced rheumatoid arthritis due to severe joint destruction and instability. - It results from progressive articular and periarticular destruction, especially affecting the **ligaments** and **cartilage**, leading to asymmetric changes in both knees. *Osteoarthritis* - While osteoarthritis can cause **varus** or **valgus deformities** in the knee, it is typically unilateral or causes similar deformities in both knees due to cartilage loss [1]. - It does not typically present with the characteristic **contralateral deformities** seen in a windswept knee [1]. *Ankylosing Spondylitis* - Primarily affects the **axial skeleton** (spine and sacroiliac joints), leading to stiffness and fusion. - Peripheral joint involvement, when present, usually affects large joints but does not typically manifest as a **windswept deformity** of the knees. *Psoriatic arthritis* - Can affect peripheral joints, sometimes causing **arthritis mutilans** or **dactylitis**. - While it can cause joint deformities, a specific **windswept deformity** of the knees is not a characteristic or common feature.

Question 713: Uveoparotitis is seen in

A. Sjogren's syndrome
B. Rheumatoid arthritis
C. SLE
D. Sarcoidosis (Correct Answer)

Explanation: ***Sarcoidosis*** - **Uveoparotitis** (inflammation of the uveal tract of the eye and the parotid glands) is a classic manifestation of **sarcoidosis**, particularly when associated with **facial nerve palsy (Heerfordt's syndrome)**. - Sarcoidosis is a multisystem granulomatous disease that can affect various organs, including the eyes, salivary glands, and lungs. *Sjogren's syndrome* - Characterized by **dry eyes** (keratoconjunctivitis sicca) and **dry mouth** (xerostomia) due to immune-mediated destruction of exocrine glands. - While it can involve the parotid glands, it typically causes chronic inflammation leading to dryness, not necessarily acute uveoparotitis. *Rheumatoid arthritis* - Primarily an inflammatory arthritis affecting **synovial joints**, leading to joint destruction and deformity. - Ocular involvement can include **scleritis** or **episcleritis**, but not typically uveitis or parotitis as a combined syndrome. *SLE* - A systemic autoimmune disease with diverse manifestations, including kidney disease, skin rashes, and arthritis. - Ocular manifestations can include **retinal vasculitis** or **conjunctivitis**, but uveitis and parotitis as a specific syndrome like uveoparotitis are not characteristic.

Question 714: Antinuclear-antibodies are present in what percentage of cases of SLE ?

A. 70%
B. 50%
C. 80%
D. More than 90% (Correct Answer)

Explanation: ***More than 90%*** - **Antinuclear antibodies (ANAs)** are detected in over 90% of patients with **systemic lupus erythematosus (SLE)** [1]. - Due to their very high sensitivity, ANAs are a crucial **screening test** for SLE, and a negative ANA test makes the diagnosis of SLE highly unlikely [1]. *70%* - While ANA positivity is essential for SLE diagnosis, 70% is **too low** to reflect the true prevalence of ANAs in SLE patients [1]. - A sensitivity of 70% would mean a relatively high number of false negatives, which is not characteristic of ANA for SLE. *50%* - A 50% positivity rate is **significantly lower** than the established prevalence for ANAs in SLE, which is typically above 90% [1]. - Such a low percentage would make the ANA test a poor screening tool for SLE, which contradicts its clinical utility. *80%* - An 80% ANA positivity rate is still **lower than the generally accepted figure**, which is often cited as 95-98% in most cases of active SLE [1]. - While 80% is high, it doesn't quite capture the near-universal presence of ANAs in SLE, which is why it is used as an initial screening marker.

Question 715: All are seronegative spondyloarthritides with ocular manifestations, except

A. Psoriatic arthritis
B. Rheumatoid arthritis (Correct Answer)
C. Ankylospondylitis
D. Reiter's disease

Explanation: ***Rheumatoid arthritis*** - While rheumatoid arthritis can have **ocular manifestations** (e.g., **scleritis**, **keratoconjunctivitis sicca**) [1], it is categorized as a **seropositive** arthritis due to the presence of **rheumatoid factor** and **anti-CCP antibodies** in most cases. - The question specifically asks for a condition that is *not* a seronegative spondyloarthritide. *Psoriatic arthritis* - This is a **seronegative spondyloarthritide** and can present with various **ocular manifestations**, including **conjunctivitis** and **uveitis**. - It lacks **rheumatoid factor** and typically involves the skin and joints. *Ankylospondylitis* - This is a classic example of a **seronegative spondyloarthritide**, strongly associated with **HLA-B27** [2]. - **Acute anterior uveitis** is a common ocular complication, affecting up to 40% of patients [2]. *Reiter's disease* - Now more commonly referred to as **reactive arthritis**, it is a **seronegative spondyloarthritide** by definition. - Ocular manifestations are prominent and include **conjunctivitis** and **anterior uveitis**, often part of the classic triad (arthritis, urethritis, conjunctivitis) [2].

Question 716: Deposition of Anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen in:

A. Good pasture
B. Raynauds disease
C. SLE (Correct Answer)
D. Scleroderma

Explanation: ### SLE - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are involved in the pathophysiology of organ damage in this autoimmune disease [2]. - The deposition of these antibodies and immune complexes in various tissues like the **kidney (lupus nephritis)**, **skin (malar rash, discoid lupus)**, **choroid plexus (neuropsychiatric lupus)**, and **joints (arthralgia/arthritis)** is characteristic of SLE [1]. ### Good pasture - Goodpasture syndrome is characterized by **anti-glomerular basement membrane (anti-GBM) antibodies** that primarily target the **kidneys** and **lungs**. - It does not involve the deposition of anti-dsDNA antibodies or affect the skin, choroid plexus, or joints in the same manner as SLE. ### Raynauds disease - Raynaud's disease is a **vasospastic disorder** affecting small arteries, typically in the fingers and toes, leading to episodic color changes (white, blue, red). - It is not an autoimmune disease characterized by antibody deposition in organs, although it can be a symptom of underlying connective tissue diseases like SLE [1]. ### Scleroderma - Scleroderma (systemic sclerosis) is an autoimmune disease characterized by **fibrosis** of the skin and internal organs, and **vascular dysfunction**. - While it can involve **autoantibodies (e.g., anti-topoisomerase I, anti-centromere)**, it is not primarily associated with anti-dsDNA antibody deposition or the specific pattern of organ involvement seen in SLE [2].

Question 717: 45-year-old man presented to outpatient department with hot, swollen left big toe and a painful lesion on the rim of his left pinna. Polarized light microscopy of the synovial fluid shows dense neutrophilic infiltrate and crystals that are negatively birefringent. Patient is likely to be suffering from?

A. Gout (Correct Answer)
B. Ankylosing spondylitis
C. Rheumatoid arthritis
D. Seronegative arthritis

Explanation: ***Gout*** - The presentation of a **hot, swollen left big toe** (podagra), a painful lesion on the **helix of the ear**, and **negatively birefringent crystals** in synovial fluid is classic for gout [1]. - These crystals are **monosodium urate**, formed from elevated uric acid levels, depositing in joints and soft tissues [1]. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton**, causing chronic back pain and stiffness that improves with exercise, and would not present with acute podagra or ear lesions. - While it can be associated with **HLA-B27**, its synovial fluid findings would not include negatively birefringent crystals. *Rheumatoid arthritis* - Characterized by **symmetric polyarthritis** primarily affecting small joints, morning stiffness lasting over 30 minutes, and typically involves positive **rheumatoid factor** and **anti-CCP antibodies**. - Synovial fluid in rheumatoid arthritis would show inflammatory changes but not the specific negatively birefringent crystals seen in gout [1]. *Seronegative arthritis* - This is a broad category including conditions like **psoriatic arthritis, reactive arthritis, and ankylosing spondylitis**, all of which lack **rheumatoid factor**. - None of these conditions typically present with **negatively birefringent crystals** in joint fluid or **tophi-like lesions** on the ear helix [1].

Question 718: A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -

A. Temporal arteritis (Correct Answer)
B. Migraine
C. Sinusitis
D. Cluster headache

Explanation: ***Temporal arteritis*** - The combination of **unilateral headache**, **visual disturbances** (blindness), a **palpable temporal artery** (thick cord-like structure), and a **markedly elevated ESR** (80 mm/hr) in an elderly patient is highly suggestive of temporal arteritis (giant cell arteritis) [1]. - This condition is an **inflammatory vasculitis** that can lead to permanent vision loss if not promptly treated with corticosteroids [1]. *Migraine* - While migraines cause **unilateral headaches**, they typically present with **photophobia**, phonophobia, and aura, and are not associated with a palpable temporal artery or such a high ESR [1]. - Blindness is not a typical persistent symptom of migraine; visual disturbances are usually transient auras [3]. *Sinusitis* - Sinusitis causes **facial pain** and headache, often localized to the sinus regions, and may be accompanied by congestion and discharge. - It does not cause permanent blindness or present with a palpable temporal artery, nor does it typically result in an ESR of 80 mm/hr. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, retro-orbital location, and autonomic symptoms like **lacrimation** and **nasal congestion**, but they do not cause a palpable temporal artery, blindness, or an elevated ESR [2]. - The pain is usually episodic and short-lived, unlike the persistent symptoms described [2].

Question 719: A 65-year-old man with history of back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in vertebrae. Diagnosis is -

A. Lumbar canal stenosis
B. Degenerative osteoarthritis of spine
C. Ankylosing hyperosteosis
D. Ankylosing spondylitis (Correct Answer)

Explanation: ***Ankylosing spondylitis*** - The presence of **syndesmophytes** on X-ray, in conjunction with **back pain**, **stiffness**, and **restricted chest movements**, are hallmark features of ankylosing spondylitis [1]. Also a **raised ESR** is consistent. - This chronic inflammatory disease primarily affects the **axial skeleton**, leading to fusion of vertebrae and progressive stiffness [1]. *Lumbar canal stenosis* - This condition involves **narrowing of the spinal canal**, which typically causes **radicular pain**, neurogenic claudication, and weakness in the legs [2]. - It does not present with restricted chest movements or syndesmophytes, and a raised ESR is not a typical finding. *Degenerative osteoarthritis of spine* - Characterized by **bone spurs (osteophytes)** and **disc space narrowing** due to wear and tear, rather than syndesmophytes. - While it causes back pain and stiffness, it typically does not lead to significant restriction of chest movements or a markedly elevated ESR associated with systemic inflammation. *Ankylosing hyperosteosis* - Also known as **Diffuse Idiopathic Skeletal Hyperostosis (DISH)**, characterized by **flowing ossification along the anterior longitudinal ligament** primarily on the right side of the spine [2]. - While it can cause stiffness and back pain, it generally does not involve a significantly elevated ESR or cause the same degree of restricted chest movement as true ankylosing spondylitis.

Question 720: Based on 1990 ACR criteria, the diagnosis of fibromyalgia is made in patients with a history of diffuse musculoskeletal pain and which of the following physical findings:

A. Symmetrical joint tenderness
B. Muscle weakness
C. Multiple areas of tendonitis
D. 11 of 18 tender points (Correct Answer)

Explanation: ***11 of 18 tender points*** - The 1990 American College of Rheumatology (ACR) criteria for fibromyalgia require a history of **widespread pain** for at least 3 months and pain in **11 of 18 specific tender points** on digital palpation [1]. - These tender points are symmetrical and located in areas such as the **occiput**, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knee [1]. *Symmetrical joint tenderness* - While patients with fibromyalgia experience widespread pain, the diagnostic criteria focus on **tender points** in soft tissues, not typically tenderness within the joint capsules themselves [1], [2]. - **Joint tenderness** can be a feature of inflammatory arthritis, which is a different condition. *Muscle weakness* - **Muscle weakness** is not a primary diagnostic criterion for fibromyalgia; patients report pain and fatigue, but objective weakness is generally not present [2]. - Muscular pain and fatigue in fibromyalgia are due to altered pain processing, not primary muscle pathology leading to weakness [1]. *Multiple areas of tendonitis* - Although patients with fibromyalgia may experience localized pain that can sometimes be mistaken for **tendonitis**, it is not a specific diagnostic criterion [1]. - True **tendonitis** involves inflammation of a tendon and is usually localized to specific areas, unlike the diffuse tender points of fibromyalgia.

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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