Rheumatology and Immunology Practice Questions

Q: Which of the following conditions is an indication for Chrysotherapy?

Rheumatoid arthritis. The explanation with [3], [1] inline citations added ***Rheumatoid arthritis*** - Chrysotherapy, specifically using **gold salts**, was an early and effective treatment for **rheumatoid arthritis (RA)**, particularly for patients with active and progressive disease. [3] - While less common today due to newer biological agents, gold compounds like **aurothiomalate** and **auranofin** were historically used to reduce inflammation and slow joint damage in RA. [1] *Ankylosing spondylitis* - **Ankylosing spondylitis** is a seronegative spondyloarthropathy primarily affecting the axial skeleton. - Its treatment typically involves **NSAIDs**, **TNF-alpha inhibitors**, and exercise, not chrysotherapy. *Behcet's syndrome* - **Behcet's syndrome** is a systemic vasculitis characterized by recurrent oral ulcers, genital ulcers, and uveitis. - Treatment usually involves **corticosteroids** and **immunosuppressants**, with no indication for chrysotherapy. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease involving cartilage breakdown. [2] - Management focuses on **pain relief**, **physical therapy**, and in severe cases, **joint replacement**, and chrysotherapy is not part of its treatment regimen. [2]

Q: Triple therapy in Rheumatoid Arthritis involves all except

Steroids. ***Steroids*** - While **steroids** (e.g., **prednisone**) are commonly used in rheumatoid arthritis to control flares and bridge therapy [1], they are not a component of the classic "triple therapy" regimen, which refers to a specific combination of **DMARDs**. - Steroids are typically used for their rapid **anti-inflammatory effects** but carry significant long-term side effects, making them unsuitable for sustained monotherapy or as part of continuous fixed-dose DMARD combinations. *Hydroxychloroquine* - **Hydroxychloroquine** is a foundational component of the traditional "triple therapy" for rheumatoid arthritis, valued for its relatively mild side effect profile. - It works by modulating immune responses and is often combined with other **DMARDs** for synergistic effects. *Sulphasalazine* - **Sulphasalazine** is another key component of the "triple therapy" regimen, particularly useful for its anti-inflammatory and immunomodulatory actions in rheumatoid arthritis. - It helps to reduce joint pain, stiffness, and swelling, working in conjunction with methotrexate and hydroxychloroquine. *Methotrexate* - **Methotrexate** is considered the cornerstone of rheumatoid arthritis treatment and is an essential part of the "triple therapy" combination [1]. - It is a **disease-modifying antirheumatic drug (DMARD)** that effectively slows disease progression and reduces joint damage.

Q: "Flexor tendon tenosynovitis" is a hallmark feature of

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Flexor tendon tenosynovitis** is a common inflammatory manifestation in **rheumatoid arthritis**, contributing to symptoms like trigger finger and carpal tunnel syndrome [2]. - It involves inflammation of the **synovial sheath** surrounding the flexor tendons, often seen in the hands and wrists. *Osteoarthritis* - Primarily a **degenerative joint disease** characterized by cartilage breakdown, not inflammation of tendon sheaths. - While osteophytes can lead to mechanical irritation, primary **tendon tenosynovitis** is not a hallmark. *Psoriatic arthritis* - Characterized by **dactylitis** (sausage digits) and enthesitis (inflammation at tendon/ligament insertions), but **flexor tendon tenosynovitis** itself is less distinctive compared to RA [1]. - It often involves asymmetrical joint inflammation and skin/nail psoriasis [1]. *Ankylosing spondylitis* - A form of **spondyloarthritis** primarily affecting the axial skeleton (spine and sacroiliac joints) and entheses. - **Flexor tendon tenosynovitis** is not a typical or hallmark feature of this condition, which is more associated with spinal stiffness and pain.

Q: Which of the following is NOT a characteristic feature of Henoch-Schönlein purpura (HSP)?

Thrombocytopenia. ***Thrombocytopenia*** - **Thrombocytopenia** is generally **not a feature** of Henoch-Schönlein purpura (HSP); platelet counts are typically **normal** or can even be elevated [1]. - HSP is a **vasculitis**, characterized by **IgA deposition**, leading to palpable purpura, rather than a primary platelet disorder [1]. *Splinter hemorrhage* - **Splinter hemorrhages** are a form of **microembolism** or capillary damage that can occur in various conditions, and while not a cardinal feature, they are more related to vessel damage than thrombocytopenia. - Although less common, any form of **vasculitis-related capillary leakage** could theoretically lead to small hemorrhagic phenomena. *Abdominal pain* - **Abdominal pain** is a very common and significant symptom in HSP, often due to **gastrointestinal vasculitis** leading to bowel wall edema, hemorrhage, or intussusception. - It can range from mild discomfort to severe, colicky pain and may be accompanied by **gastrointestinal bleeding**. *Epistaxis* - **Epistaxis** (nosebleeds) is a possible manifestation of **mucosal vasculitis** in HSP. - It can occur due to damage to superficial blood vessels in the nasal passages as part of the systemic inflammatory process.

Q: Distal interphalangeal joints are involved in all except -

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Rheumatoid arthritis** characteristically spares the **distal interphalangeal (DIP) joints** while commonly affecting the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints [1]. - Involvement of the DIP joints would suggest an alternative diagnosis or atypical presentation [5]. *Psoriatic arthritis* - **Psoriatic arthritis** frequently involves the **DIP joints**, leading to classic "sausage digits" (dactylitis) and nail changes [1]. - It often gives a "pencil-in-cup" appearance on X-ray due to erosions at these joints [3]. *Reactive arthritis* - **Reactive arthritis** can affect any joint, including the **DIP joints**, although it more commonly presents in a **mono- or oligoarticular** pattern, predominantly in the lower limbs [4]. - The pattern of joint involvement is typically asymmetric [4]. *Osteoarthritis* - **Osteoarthritis** commonly affects the **DIP joints**, leading to the formation of **Heberden's nodes** (bony enlargements at the DIP joints) [2]. - This is a hallmark feature of generalized osteoarthritis, especially in the hands [2].

Q: True statement about Rheumatic fever in children -

Polyarthritis is the most common major manifestation. ***Polyarthritis is the most common major manifestation*** - **Polyarthritis** is a migratory inflammation of large joints, typically affecting more than one joint simultaneously or in quick succession, and is indeed the most frequent major manifestation of acute rheumatic fever in children. - It affects about **60-80%** of children with episodes of rheumatic fever, usually resolving without permanent joint damage. *MC valve involvement is Aortic* - The **mitral valve** is the most commonly affected heart valve in rheumatic fever, experiencing damage in 50-70% of cases [1]. - While the aortic valve can be involved, it is less common than mitral valve involvement, with tricuspid and pulmonary valves being affected least frequently. *Caused by Group A beta-hemolytic streptococci* - Acute rheumatic fever is an **autoimmune inflammatory process** that occurs as a sequela of an untreated or inadequately treated infection with Group A Streptococcus (GAS), not directly caused by the bacteria [1]. - The immune response to GAS (specifically *Streptococcus pyogenes*) leads to **molecular mimicry**, where antibodies mistakenly attack host tissues, primarily the heart, joints, brain, and skin [2]. *Erythema marginatum is the most common manifestation* - **Erythema marginatum** is a rare rash associated with rheumatic fever, characterized by red rings or crescent-shaped lesions with clear centers, primarily seen on the trunk and proximal extremities. - It is one of the **minor manifestations** and occurs in less than 5% of cases, making it far from the most common overall manifestation (major or minor).

Q: All of the following features may be used to distinguish PAN from microscopic polyangitis, except:

Necrotizing vasculitis. ***Necrotizing vasculitis*** - Both **polyarteritis nodosa (PAN)** and **microscopic polyangiitis (MPA)** are characterized by **necrotizing vasculitis**, making it a shared feature rather than a distinguishing one. [1] - This pathological finding describes the **inflammation** and **necrosis** of vessel walls, which is central to the pathogenesis of both conditions. [1] *RBC cast in urine* - **Red blood cell (RBC) casts** in the urine are indicative of **glomerulonephritis**, which is a prominent feature of **microscopic polyangiitis (MPA)** but typically absent in **polyarteritis nodosa (PAN)**. [1] - The presence of RBC casts points to **renal involvement**, particularly in the small vessels of the glomeruli, which distinguishes MPA's pattern of injury. [1] *ANCA positivity* - **Anti-neutrophil cytoplasmic antibodies (ANCAs)**, particularly **p-ANCA (MPO-ANCA)**, are frequently positive in **microscopic polyangiitis (MPA)** but usually negative in **polyarteritis nodosa (PAN)**. - ANCA positivity helps classify MPA as an **ANCA-associated vasculitis**, a distinction not typically applied to PAN. *HBV infection* - **Hepatitis B virus (HBV) infection** is strongly associated with a significant subset of **polyarteritis nodosa (PAN)** cases, whereas this association is rare in **microscopic polyangiitis (MPA)**. - Serological testing for HBV can therefore help differentiate between the two conditions, with a positive result favoring PAN.

Q: Which of the following is NOT a connective tissue disorder?

Sjogren's syndrome. ***Sjogren's syndrome*** - Sjogren's syndrome is an **autoimmune disease** characterized by **dry eyes** and **dry mouth**, resulting from immune-mediated destruction of exocrine glands [1]. - While it can involve multiple organ systems and is classified as a **systemic autoimmune disorder**, it is primarily an **exocrinopathy**, and not exclusively a disorder of connective tissue structure or function. *Osteoarthritis* - Osteoarthritis is a **degenerative joint disease** primarily affecting the **articular cartilage** and underlying bone. - While it involves destruction of cartilage, which is a connective tissue, it is considered a **degenerative rather than a systemic inflammatory or autoimmune connective tissue disorder**. *Fibromyalgia* - Fibromyalgia is a chronic pain condition characterized by **widespread musculoskeletal pain**, fatigue, and sleep disturbances, without evidence of inflammation or tissue damage [3]. - It is considered a **central sensitization syndrome** rather than a disorder of the connective tissue itself [3]. *SLE* - Systemic lupus erythematosus (SLE) is a **prototypical systemic autoimmune connective tissue disorder** affecting multiple organ systems [2]. - It is characterized by **autoantibody production** and immune complex deposition, leading to inflammation and damage in joints, skin, kidneys, and other tissues [2].

Q: Antibodies most specific for drug induced lupus are -

Antihistone. ***Antihistone*** - **Antihistone antibodies** are present in 95% of patients with **drug-induced lupus erythematosus (DILE)**, making them the most specific marker for this condition. - The disease often resolves upon discontinuation of the culprit drug, and antihistone antibody levels typically decrease. *ANA* - **Antinuclear antibodies (ANA)** are present in nearly all forms of lupus, including DILE, but are **not specific** for drug-induced forms as they are also found in SLE and other autoimmune diseases [1]. - A positive ANA test is often the initial screening test for lupus but requires further, more specific antibody testing for differentiation. *Anti Sm* - **Anti-Smith (Anti-Sm) antibodies** are highly specific for **systemic lupus erythematosus (SLE)** [1], but are rarely seen in DILE. - Their presence strongly suggests a diagnosis of SLE and not drug-induced lupus. *Anti ds DNA* - **Anti-double-stranded DNA (Anti-dsDNA) antibodies** are highly specific for **systemic lupus erythematosus (SLE)** and are often associated with disease activity and **lupus nephritis**. - These antibodies are typically **absent** or present in very low titers in DILE, differentiating it from SLE.

Q: Most common manifestation of rheumatic fever –

Arthritis. ***Arthritis*** - **Polyarthritis** is the most common major manifestation of acute rheumatic fever (ARF), affecting up to 75% of patients. - It typically presents as a **migratory arthritis** affecting large joints such as knees, ankles, elbows, and wrists, resolving without sequelae. *Chorea* - **Sydenham's chorea** (St. Vitus' dance) is a neurological manifestation characterized by sudden, involuntary, jerky movements, occurring in about 10-30% of ARF cases. - While a major criterion, its incidence is significantly lower than that of arthritis. *Carditis* - **Carditis** is the most serious manifestation of ARF, affecting 40-70% of patients and often leading to chronic rheumatic heart disease. - Although it has the highest mortality and morbidity, its frequency is less than that of arthritis. *Nodules* - **Subcutaneous nodules** are rare manifestations of ARF, typically appearing on extensor surfaces of joints or the spine, and are usually painless. - They occur in less than 1-2% of cases, making them one of the least common major criteria.

Question 1

Which of the following conditions is an indication for Chrysotherapy?

Accepted Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Behcet's syndrome

Answer

Osteoarthritis

Question 2

Triple therapy in Rheumatoid Arthritis involves all except

Accepted Answer

Steroids

Answer

Hydroxychloroquine

Answer

Sulphasalazine

Answer

Methotrexate

Question 3

"Flexor tendon tenosynovitis" is a hallmark feature of

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Answer

Ankylosing spondylitis

Question 4

Which of the following is NOT a characteristic feature of Henoch-Schönlein purpura (HSP)?

Accepted Answer

Thrombocytopenia

Answer

Splinter hemorrhage

Answer

Abdominal pain

Answer

Epistaxis

Question 5

Distal interphalangeal joints are involved in all except -

Accepted Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Reactive arthritis

Answer

Osteoarthritis

Question 6

True statement about Rheumatic fever in children -

Accepted Answer

Polyarthritis is the most common major manifestation

Answer

MC valve involvement is Aortic

Answer

Caused by Group A beta-hemolytic streptococci

Answer

Erythema marginatum is the most common manifestation

Question 7

All of the following features may be used to distinguish PAN from microscopic polyangitis, except:

Accepted Answer

Necrotizing vasculitis

Answer

RBC cast in urine

Answer

ANCA positivity

Answer

HBV infection

Question 8

Which of the following is NOT a connective tissue disorder?

Accepted Answer

Sjogren's syndrome

Answer

Osteoarthritis

Answer

Fibromyalgia

Answer

SLE

Question 9

Antibodies most specific for drug induced lupus are -

Accepted Answer

Antihistone

Answer

ANA

Answer

Anti Sm

Answer

Anti ds DNA

Question 10

Most common manifestation of rheumatic fever –

Accepted Answer

Arthritis

Answer

Chorea

Answer

Carditis

Answer

Nodules

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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