Rheumatology and Immunology Practice Questions

Q: What is a rare condition associated with Hepatitis B infection?

Polyarteritis nodosa. ***Polyarteritis nodosa*** - **Polyarteritis nodosa (PAN)** is a **necrotizing vasculitis** [1] strongly associated with **Hepatitis B virus (HBV)** infection, particularly in areas where HBV is endemic. - The circulating **immune complexes** formed by HBV antigens and antibodies are deposited in the walls of small and medium-sized arteries, leading to inflammation and tissue damage. *Wegener's granulomatosis* - Now known as **Granulomatosis with Polyangiitis (GPA)**, this condition is primarily associated with **antineutrophil cytoplasmic antibodies (ANCAs)**, particularly **c-ANCA**, and is not typically linked to Hepatitis B infection. - It is characterized by necrotizing granulomatous inflammation and vasculitis affecting the respiratory tract and kidneys. *Systemic lupus erythematosus* - **Systemic lupus erythematosus (SLE)** is an **autoimmune disease** characterized by widespread inflammation and damage to various organ systems, often involving **antinuclear antibodies (ANAs)** [2], [3]. - While it can be triggered by various factors, a direct and strong association with Hepatitis B infection is not a known characteristic. *Sjogren syndrome* - **Sjogren syndrome** is a chronic autoimmune disorder primarily affecting the **exocrine glands**, leading to **dry eyes** and **dry mouth**, and is associated with **anti-Ro/SSA** and **anti-La/SSB antibodies** [2]. - While autoimmune conditions can rarely coexist or be triggered by viral infections, a direct or common association between Sjogren syndrome and Hepatitis B infection is not established.

Q: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?

Lupus nephritis. ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.

Q: The patient is presenting with a finger deformity. The PIP joint is involved, but the DIP joint is spared. There is symmetric MCP and PIP synovitis, prolonged morning stiffness lasting more than one hour, and positive anti-CCP antibodies. Refer to the image for details.

Rheumatoid arthritis of the finger. ***Rheumatoid arthritis of the finger*** - **Rheumatoid arthritis (RA)** classically affects the **PIP joints** of the fingers while sparing the **DIP joints**. - Common deformities in RA include **swan neck** and **boutonnière** deformities, often involving the PIP joints. *Osteoarthritis of the finger* - **Osteoarthritis (OA)** typically affects the **DIP joints** (Heberden's nodes) and potentially the PIP joints (Bouchard's nodes). - OA manifests with **hard, bony enlargements** and morning stiffness that improves with activity. *Psoriatic arthritis of the finger* - **Psoriatic arthritis (PsA)** often involves the **DIP joints** and can present with "sausage digits" (dactylitis), which is a diffuse swelling of an entire digit. - The presence of accompanying **psoriasis** of the skin or nails is a key differentiating feature. *Ankylosing spondylitis of the finger* - **Ankylosing spondylitis (AS)** primarily affects the **axial skeleton** (spine and sacroiliac joints), causing inflammatory back pain and stiffness. - Peripheral joint involvement in AS, particularly in the fingers, is **uncommon** and not its hallmark presentation.

Q: A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.

SLE. ***SLE*** - The combination of **oral ulcers**, **photosensitivity**, and a **malar rash** that spares the nasolabial folds is highly characteristic of **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is an autoimmune disease with diverse clinical manifestations involving multiple organ systems. *Sturge weber syndrome* - This is a neurocutaneous disorder characterized by a **port-wine stain** (nevus flammeus) typically on the face, neurological abnormalities like seizures, and ocular involvement. - It does not present with oral ulcers or photosensitivity as primary features. *Dermatitis* - **Dermatitis** is a general term for skin inflammation, often presenting with redness, itching, and sometimes blisters. - It does not typically involve the specific constellation of oral ulcers, photosensitivity, and a malar rash that spares nasolabial folds. *Psoriasis* - **Psoriasis** is a chronic autoimmune disease primarily affecting the skin, characterized by red, scaly patches (plaques) [2]. - While it can cause nail changes and sometimes joint pain, it does not present with photosensitivity, oral ulcers, or the characteristic malar rash described.

Q: Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

ANCA is typically negative in PAN.. ***30% of people have HbsAg positive*** - Hepatitis B virus infection is associated with **polyarteritis nodosa (PAN)**, with **30%** of patients having a positive **HbsAg**. - The presence of **HbsAg** indicates active Hepatitis B, which can lead to vasculitis seen in PAN. *Microscopy shows fibrinoid necrosis in large arteries* - While fibrinoid necrosis is present in vasculitides [1], it is more characteristic of **granulomatosis with polyangiitis** (Wegener's) rather than PAN. - PAN typically shows **intranuclear inclusions** and necrotizing vasculitis without predominant fibrinoid necrosis. *Patient have hypogammaglobulinemia* - Patients with PAN do not typically present with **hypogammaglobulinemia**; rather, they may have normal immunoglobulin levels. - Hypogammaglobulinemia is more commonly associated with other types of vasculitis, such as **SLE** or **chronic infections**. *ANCA is positive* - Perinuclear anti-neutrophil cytoplasmic antibodies (**ANCA**) are usually associated with **granulomatosis and eosinophilic granulomatosis** rather than PAN. - PAN is **ANCA-negative** and is characterized by alternate antibodies, particularly if associated with Hepatitis B.

Q: A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

Osteoarthritis. ***Osteoarthritis*** - **Osteoarthritis** typically affects the **1st carpometacarpal (CMC)* joint (of which the 1st MCP is a part), **proximal interphalangeal (PIP)**, and **distal interphalangeal (DIP)** joints, consistent with the patient's presentation [1]. - It classically **spares the wrist and ankle joints** in its early stages, supporting this diagnosis. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints symmetrically, but typically **spares the distal interphalangeal (DIP) joints** [1]. - It frequently involves the **wrist and ankle joints**, which are noted as spared in this case [1]. *Psoriatic arthritis* - **Psoriatic arthritis** can affect DIP joints and may present with different patterns, but a classic presentation often includes **dactylitis** (sausage digits) or nail changes, which are not mentioned [1]. - While it can affect the hand joints, the specific pattern described, including the sparing of the wrist and ankle, is not its most typical presentation. *Gout* - **Gout** is characterized by acute, severe pain, typically in a single joint, with the **first metatarsophalangeal (MTP) joint** (of the big toe) being most commonly affected, known as podagra. - While gout can affect other joints, its episodic nature and acute inflammatory presentation differ from the chronic, progressive pattern suggested by the question.

Q: 14-year-old child with Juvenile Idiopathic Arthritis (JIA). What should be the correct treatment for this condition?

DMARD with short course of Steroids. **DMARD with short course of Steroids** - **DMARDs (disease-modifying antirheumatic drugs)**, such as methotrexate, are the cornerstone of JIA treatment to control the disease and prevent joint damage. - A **short course of corticosteroids** can be used as a bridge therapy to quickly reduce inflammation and pain while DMARDs take effect. *Only NSAIDs* - **NSAIDs (nonsteroidal anti-inflammatory drugs)** are used for symptomatic relief of pain and inflammation. - They do not alter the disease course or prevent joint destruction in JIA. *DMARD after initial 3 months of NSAIDs* - Delaying DMARD initiation for 3 months with only NSAIDs is generally not recommended, especially in patients with active JIA. - Early and aggressive DMARD therapy is crucial to prevent progressive joint damage and achieve remission. *Monotherapy with TNF drugs* - **TNF inhibitors (biologics)** are powerful DMARDs, but they are typically reserved for patients who have an inadequate response to conventional DMARDs (e.g., methotrexate monotherapy). - They are generally not used as initial monotherapy unless specific risk factors or severe forms of JIA warrant it.

Q: Sausage finger appearance is associated with which of the following conditions?

Psoriatic arthritis. ***Psoriatic arthritis*** - **Dactylitis**, or "sausage finger," is a characteristic inflammatory finding in psoriatic arthritis, resulting from inflammation of the **entire digit** [1]. - This condition involves inflammation of tendons, joints, and soft tissues which leads to diffuse swelling of fingers or toes [1]. *Rickets* - Rickets is a bone-softening disease in children caused by **vitamin D deficiency**, leading to bone deformities like bowed legs or widened wrists. - It does not present with inflammatory dactylitis or "sausage digits." *Hyperthyroidism* - Hyperthyroidism is a condition of excessive thyroid hormone production, which can cause symptoms like **tremors**, **tachycardia**, and **weight loss** [2]. - It is not associated with dactylitis or changes in finger morphology. *Addison's disease* - Addison's disease results from **adrenal insufficiency**, leading to symptoms like **fatigue**, **skin hyperpigmentation**, and hypotension. - There is no clinical association between Addison's disease and "sausage finger" appearance.

Q: Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

ANCA. ### ANCA - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points towards a small-vessel vasculitis, for which **ANCA (anti-neutrophil cytoplasmic antibodies)** testing is crucial [1]. - ANCA is highly specific for conditions like **Granulomatosis with Polyangiitis (GPA)** and **Microscopic Polyangiitis (MPA)** [1]. ### RA factor - **Rheumatoid factor (RF)** is primarily associated with **rheumatoid arthritis**, which typically presents with symmetrical polyarthritis, not the constellation of symptoms described. - While RF can be positive in some vasculitides, it is not the most specific initial test for the given clinical presentation. ### Hbsag - **Hepatitis B surface antigen (HbsAg)** typically screens for **Hepatitis B infection**, which can cause **polyarteritis nodosa (PAN)**, a medium-vessel vasculitis. - However, the patient's symptoms (cutaneous vasculitis, glomerulonephritis) are more characteristic of **small-vessel vasculitis**, making ANCA a more direct investigation [1]. ### MIF - **MIF (Macrophage Migration Inhibitory Factor)** is a cytokine involved in inflammation, but it is not a routine diagnostic marker for vasculitis. - It is not used as a primary investigation to diagnose specific autoimmune or inflammatory conditions like vasculitis.

Q: Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

Presence of rheumatoid factor (RF). Presence of rheumatoid factor (RF) - **Seropositive rheumatoid arthritis** is specifically defined by the presence of **rheumatoid factor (RF)** or anti-citrullinated protein antibodies (anti-CCP), indicating a particular immunological subtype of the disease [1]. - The detection of **RF**, an autoantibody, is a key diagnostic marker that helps differentiate seropositive RA from seronegative forms and other inflammatory arthritides [1]. Joint deformities - Joint deformities, such as **ulnar deviation** or **boutonnière and swan neck deformities**, are a common *consequence* of chronic, uncontrolled rheumatoid arthritis [2]. - While characteristic of advanced disease, deformities are not a *defining feature* for the initial classification of **seropositive RA**, which is based on serological markers. Morning stiffness lasting more than 30 minutes - **Morning stiffness** that persists for more than 30 minutes is a classic *symptom* of inflammatory arthritis, including both seropositive and seronegative RA [3]. - Although it is an important diagnostic criterion for RA in general, it is not specific to the **seropositive subtype** because it can be present in other inflammatory arthropathies as well [3]. Generalized joint pain and swelling - **Generalized joint pain and swelling**, typically in a symmetrical pattern affecting small joints, are core *symptoms* of rheumatoid arthritis and indicate active inflammation [3]. - These symptoms are common in all forms of RA, including both seropositive and seronegative, and thus do not specifically characterize the **seropositive subtype**.

Question 1

What is a rare condition associated with Hepatitis B infection?

Accepted Answer

Polyarteritis nodosa

Answer

Wegener's granulomatosis

Answer

Systemic lupus erythmatosus

Answer

Sjogren syndrome

Question 2

A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and    new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely    diagnosis?

Accepted Answer

Lupus nephritis

Answer

Acute interstitial nephritis

Answer

Poststreptococcal glomerulonephritis

Answer

IgA nephropathy

Question 3

The patient is presenting with a finger deformity. The PIP joint is involved, but the DIP joint is spared. There is symmetric MCP and PIP synovitis, prolonged morning stiffness lasting more than one hour, and positive anti-CCP antibodies. Refer to the image for details.

Accepted Answer

Rheumatoid arthritis of the finger

Answer

Ankylosing spondylitis of the finger

Answer

Psoriatic arthritis of the finger

Answer

Osteoarthritis of the finger

Question 4

A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.

Accepted Answer

SLE

Answer

Sturge weber syndrome

Answer

Dermatitis

Answer

Psoriasis

Question 5

Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

Accepted Answer

ANCA is typically negative in PAN.

Answer

Patients with PAN may exhibit hypergammaglobulinemia.

Answer

Approximately 30% of patients with Polyarteritis Nodosa (PAN) are HBsAg positive.

Answer

Microscopy shows fibrinoid necrosis in medium-sized arteries

Question 6

A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Gout

Question 7

14-year-old child with Juvenile Idiopathic Arthritis (JIA). What should be the correct treatment for this condition?

Accepted Answer

DMARD with short course of Steroids

Answer

Only NSAID’S

Answer

DMARD after initial 3 months of NSAID’S

Answer

Monotherapy with TNF drugs

Answer

Question 8

Sausage finger appearance is associated with which of the following conditions?

Accepted Answer

Psoriatic arthritis

Answer

Rickets

Answer

Hyperthyroidism

Answer

Addison's disease

Question 9

Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

Accepted Answer

ANCA

Answer

RA factor

Answer

Hbsag

Answer

MIF

Question 10

Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

Accepted Answer

Presence of rheumatoid factor (RF)

Answer

Generalized joint pain and swelling

Answer

Morning stiffness lasting more than 30 minutes

Answer

Joint deformities

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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