Rheumatology and Immunology Practice Questions

Q: In gout tophi are not seen in?

Muscles. ***Muscles*** - **Muscles** are not a typical site for the formation of **tophi** in gout because they have a rich blood supply and are constantly undergoing metabolic activity, aiding in the clearance of uric acid crystals. - Tophaceous deposits primarily occur in tissues with **poor vascularity** and lower temperatures, where uric acid crystals can more easily precipitate and accumulate. *Nasal cartilage* - **Cartilage**, including the **nasal cartilage**, is a common site for tophi due to its **avascular** nature, which allows for easier deposition of **uric acid crystals** [1]. - Tophi in cartilage can manifest as painless or tender nodules. *Skin* - **Skin**, especially around joints or on the ear helix, is a frequent location for **tophi** formation, appearing as subcutaneous nodules [1]. - These deposits are often visible through the skin and can ulcerate if left untreated [1]. *Synovium* - The **synovium** is a primary target of gout, with **uric acid crystal deposition** leading to inflammatory arthritis [2]. - While acute inflammation involves the release of crystals into the synovial fluid, persistent high urate levels can lead to **tophaceous deposits** within the synovial membrane itself, contributing to chronic joint damage [1].

Q: Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Angioneurotic edema. ***Angioneurotic edema*** - The rapid onset of **laryngeal edema**, **stridor**, **hoarseness**, and **tongue swelling** following peanut consumption points to an allergic reaction, specifically **anaphylaxis** causing angioedema [1], [2]. - This is a life-threatening condition due to potential **airway obstruction**. *Foreign body bronchus* - While a foreign body could cause **stridor** if large enough to impact the trachea, symptoms like **laryngeal edema** and **tongue swelling** are not typical. - It usually presents with sudden coughing, wheezing, and possibly dyspnea, often without rapid-onset, diffuse swelling. *Foreign body larynx* - A foreign body in the larynx might cause hoarseness and stridor, but **laryngeal edema** and **tongue swelling** are not primary features of a simple foreign body obstruction. - The history of peanut ingestion and rapid systemic inflammatory response makes an allergic reaction more likely [2]. *Pharyngeal abscess* - A pharyngeal abscess typically develops more slowly, with symptoms including **severe sore throat**, **fever**, and **difficulty swallowing**. - It would not usually present with the rapid onset of severe **laryngeal edema** and **tongue swelling** immediately after peanut consumption.

Q: Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Libman-Sacks endocarditis. ***Libman-Sacks endocarditis*** - Libman-Sacks endocarditis is a **non-infectious valvular vegetation** that is highly characteristic of **systemic lupus erythematosus (SLE)** [3]. - These vegetations can lead to **valvular incompetence** or **stenosis**, primarily affecting the **mitral and aortic valves** [1]. *Mitral valve prolapse* - While mitral valve prolapse can occur in SLE patients, it is a relatively common condition in the general population and is **not as specifically linked** to SLE pathology as Libman-Sacks endocarditis. - It involves the **leaflet(s) of the mitral valve bulging** back into the left atrium during systole, which causes a **mid-systolic click and late systolic murmur**, but does not represent the specific immune-mediated damage seen in SLE. *Hemorrhagic pericarditis* - Pericarditis is a common cardiac manifestation in SLE, leading to **inflammation of the pericardium**, but it is typically **serous or fibrinous**, not usually hemorrhagic. - **Hemorrhagic pericarditis** is more often associated with conditions like malignancy, tuberculosis, or trauma, and is not a typical presentation of SLE. *Infective endocarditis* - **Infective endocarditis** is caused by microbial infection of the heart valves, resulting in **vegetations containing bacteria or fungi** [2]. - While SLE patients can be at increased risk for infections due to immunosuppression, the vegetations of Libman-Sacks endocarditis are **sterile (non-infectious)** and distinct in their underlying pathophysiology [1].

Q: All are true regarding Ankylosing spondylitis except -

More common in females. ***More common in females*** - **Ankylosing spondylitis** (AS) is **more common in males** than females, with a male-to-female ratio typically ranging from 2:1 to 3:1. - While females can be affected, their disease presentation might be milder and diagnosis often delayed. *Sacroilitis* - **Sacroiliitis** is a hallmark feature and often the **earliest radiographic finding** in ankylosing spondylitis, characterized by inflammation of the sacroiliac joints [1]. - It is crucial for the diagnosis of AS, causing **buttock pain** and stiffness [1]. *HLA -B27* - The presence of the **HLA-B27** allele is strongly associated with ankylosing spondylitis, found in **90-95% of Caucasian patients** with AS [1]. - While not diagnostic on its own, it significantly increases the risk and supports the diagnosis in conjunction with clinical and imaging findings [1]. *Iridocyclitis* - **Acute anterior uveitis (iritis or iridocyclitis)** is a common **extra-articular manifestation** of ankylosing spondylitis, affecting approximately 25-40% of patients [1]. - It presents with **eye pain**, redness, and photophobia, and can precede or follow the onset of joint symptoms.

Q: Which of the following is true about psoriatic arthritis

All of the options. ***All of the options*** - **Psoriatic arthritis** is a seronegative spondyloarthropathy [2] that can manifest with a wide range of joint involvement, including **sacroiliitis**, characteristic radiological changes like **pencil-in-cup deformity**, and involvement of both **distal** and **proximal interphalangeal joints** [1]. *Sacroiliitis is a common feature* - **Sacroiliitis** occurs in approximately 20-40% of patients with psoriatic arthritis, contributing to inflammatory back pain. - It is often **asymmetrical** and can be detected radiographically [1], distinguishing it from the typically symmetrical sacroiliitis of ankylosing spondylitis. *Pencil in cup deformity is a radiological finding* - This characteristic radiological finding, known as **arthritis mutilans**, is seen in a severe subtype of psoriatic arthritis where there is **osteolysis** of the phalanx and telescoping of the digit [2]. - It results from severe bone erosion at the joint margins, creating a "pencil-in-cup" appearance. *Involves distal joints of hand and foot and proximal interphalangeal joints* - **DIP joint involvement** (distal interphalangeal) is a classic feature of psoriatic arthritis, distinguishing it from rheumatoid arthritis [1], [2]. - Involvement of the **PIP joints** (proximal interphalangeal) and other peripheral joints is also common [1], along with **dactylitis** (sausage digits) and **enthesitis**.

Q: Bechterew disease is?

Ankylosing spondylitis. ***Ankylosing spondylitis*** - **Bechterew disease** is an older term sometimes used to refer to **ankylosing spondylitis**. [1] - It is a chronic inflammatory disease primarily affecting the **axial skeleton**, including the spine and sacroiliac joints. [1] *Beh''et''s disease* - This is a separate chronic, systemic inflammatory disease characterized by **recurrent oral and genital ulcers**, **skin lesions**, and **ocular involvement**. - It does not primarily affect the spine in the same way as ankylosing spondylitis and is not known as Bechterew disease. *Sjogren''s syndrome* - This is an **autoimmune disease** primarily characterized by **dry eyes** (**xerophthalmia**) and **dry mouth** (**xerostomia**) due to lymphocytic infiltration of exocrine glands. - It is not referred to as Bechterew disease and has distinct clinical features from ankylosing spondylitis. *Psoriasis* - This is a chronic **autoimmune skin condition** characterized by red, scaly patches on the skin, often associated with **psoriatic arthritis**. [1] - While psoriatic arthritis can involve the spine, psoriasis itself is a skin condition and is not synonymous with Bechterew disease. [1]

Q: Seronegative spondarthritides includes all EXCEPT

Rheumatoid arthritis. ***Rheumatoid arthritis*** - Rheumatoid arthritis (RA) is characterized by the presence of **rheumatoid factor (RF)** and/or **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, making it a **seropositive** arthropathy. [1] - While it causes an inflammatory arthritis, its serological markers differentiate it from the seronegative spondyloarthropathies. *Reiter's syndrome* - Reiter's syndrome, now commonly referred to as **reactive arthritis**, is a classic example of a seronegative spondyloarthropathy. [1] - It is often triggered by an infection and is typically **RF-negative** and **HLA-B27 positive**. *Ankylosing spondylitis* - **Ankylosing spondylitis (AS)** is a prototypical seronegative spondyloarthropathy, characterized by inflammation primarily affecting the **spine and sacroiliaciac joints**. [1] - It is defined by the **absence of RF** and **anti-CCP antibodies**, though it is strongly associated with **HLA-B27**. *Psoriatic arthritis* - **Psoriatic arthritis (PsA)** is another member of the seronegative spondyloarthropathies, occurring in individuals with **psoriasis**. [1] - Like other conditions in this group, patients with PsA are typically **negative for RF** and **anti-CCP antibodies**.

Q: Anti-histone antibodies are specific for:

Drug induced lupus. ***Drug induced lupus*** - **Anti-histone antibodies** are highly sensitive (up to 95%) for **drug-induced lupus erythematosus (DILE)**, making them a key diagnostic marker. - DILE typically resolves after discontinuation of the offending drug, and the presence of these antibodies helps differentiate it from systemic lupus erythematosus (SLE) [1]. *Neonatal lupus* - **Neonatal lupus** is associated with **anti-Ro/SSA** and **anti-La/SSB antibodies**, which are passively acquired from the mother [1]. - It primarily presents with skin rash and/or congenital heart block, not typically associated with anti-histone antibodies. *CNS lupus* - **Central nervous system (CNS) lupus** is a manifestation of **systemic lupus erythematosus (SLE)** and is associated with various autoantibodies, including **anti-ribosomal P protein antibodies** and sometimes anti-neuronal antibodies. - While patients with SLE can have anti-histone antibodies, they are not specific for CNS involvement, and other antibody profiles are more relevant to CNS manifestations. *Cutaneous lupus* - **Cutaneous lupus erythematosus (CLE)** can be a standalone condition or part of SLE; it is typically associated with **anti-Ro/SSA antibodies** in subacute cutaneous lupus and sometimes **anti-dsDNA antibodies** in acute cutaneous lupus [2]. - **Anti-histone antibodies** are not a primary diagnostic marker for the various forms of cutaneous lupus.

Q: A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis. (SELECT 1 DIAGNOSIS)

Polyarteritis nodosa. ***Polyarteritis nodosa*** - The combination of **fever**, **weight loss**, **hypertension**, **peripheral neuropathy**, **nodular skin rash**, **elevated ESR**, and **RBC casts** (indicating glomerulonephritis) is highly suggestive of **polyarteritis nodosa**. Systemic vasculitis should be considered in any patient with fever, weight loss, and multisystem involvement [1]. - **Polyarteritis nodosa** is a systemic vasculitis characterized by necrotizing inflammation of medium-sized arteries, often associated with a history of **drug abuse** and can involve multiple organ systems leading to the described symptoms [1]. *Behcet syndrome* - Characterized by recurrent **oral** and **genital ulcers**, and **uveitis**, which are not mentioned in this patient presentation. - While it can manifest with skin lesions and vasculitis, the specific constellation of symptoms, including hypertension and RBC casts, points away from **Behcet syndrome**. *Ankylosing spondylitis* - Primarily affects the **axial skeleton**, causing chronic back pain and stiffness, particularly in younger males. - It does not typically present with the systemic symptoms like **hypertension**, **nodular rash**, or **RBC casts** seen in this patient. *Polymyalgia rheumatica* - Characterized by **proximal muscle pain** and stiffness, predominantly in the shoulders, neck, and hip girdle, in older adults. - It is not associated with **hypertension**, **peripheral neuropathy**, **nodular skin rash**, or **renal involvement** (RBC casts) as described.

Q: In osteoarthritis, Bouchard nodes and Heberden's nodes are seen respectively at:

PIP and DIP. ***PIP and DIP*** - **Bouchard nodes** are bony enlargements of the **proximal interphalangeal (PIP) joints** of the fingers due to osteophyte formation. - **Heberden's nodes** are similar bony enlargements found on the **distal interphalangeal (DIP) joints** of the fingers. *DIP and MCP* - This option incorrectly associates Heberden's nodes with the MCP joints and does not correctly identify the location for Bouchard nodes. - While DIP joints are affected by Heberden's nodes, the **metacarpophalangeal (MCP) joints** are typically spared or less commonly involved in osteoarthritis compared to PIP and DIP joints. *DIP and PIP* - This option incorrectly reverses the locations for Bouchard and Heberden's nodes. - **Bouchard nodes** are found on the **PIP joints**, and **Heberden's nodes** are found on the **DIP joints**. *Palm and DIP* - This option incorrectly identifies the palm as a site for node formation in osteoarthritis. - Osteoarthritis typically affects the **interphalangeal joints** (PIP and DIP) and not the palmar aspect of the hand.

Question 1

In gout tophi are not seen in?

Accepted Answer

Muscles

Answer

Nasal cartilage

Answer

Skin

Answer

Synovium

Question 2

Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Accepted Answer

Angioneurotic edema

Answer

Foreign body bronchus

Answer

Foreign body larynx

Answer

Pharyngeal abscess

Question 3

Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Accepted Answer

Libman-Sacks endocarditis

Answer

Mitral valve prolapse

Answer

Hemorrhagic pericarditis

Answer

Infective endocarditis

Question 4

All are true regarding Ankylosing spondylitis except -

Accepted Answer

More common in females

Answer

Sacroilitis

Answer

HLA -B27

Answer

Iridocyclitis

Question 5

Which of the following is true about psoriatic arthritis

Accepted Answer

All of the options

Answer

Sacroiliitis is a common feature

Answer

Pencil in cup deformity is a radiological finding

Answer

Involves distal joints of hand and foot and proximal interphalangeal joints

Question 6

Bechterew disease is?

Accepted Answer

Ankylosing spondylitis

Answer

Behçet's disease

Answer

Sjogren's syndrome

Answer

Psoriasis

Question 7

Seronegative spondarthritides includes all EXCEPT

Accepted Answer

Rheumatoid arthritis

Answer

Reiter's syndrome

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Question 8

Anti-histone antibodies are specific for:

Accepted Answer

Drug induced lupus

Answer

Neonatal lupus

Answer

CNS lupus

Answer

Cutaneous lupus

Question 9

A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis. (SELECT 1 DIAGNOSIS)

Accepted Answer

Polyarteritis nodosa

Answer

Behcet syndrome

Answer

Ankylosing spondylitis

Answer

Polymyalgia rheumatica

Question 10

In osteoarthritis, Bouchard nodes and Heberden's nodes are seen respectively at:

Accepted Answer

PIP and DIP

Answer

DIP and MCP

Answer

DIP and PIP

Answer

Palm and DIP

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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