Rheumatology and Immunology Practice Questions

Q: Sicca syndrome is associated with all except?

Midline granuloma. Sicca syndrome is associated with all except? ***Midline granuloma*** - **Midline granuloma** (now commonly referred to as **extranodal NK/T-cell lymphoma, nasal type**) is a destructive inflammatory process primarily affecting the upper respiratory tract. It is not directly associated with the autoimmune features of sicca syndrome. - Its pathology involves an aggressive **lymphoproliferative disorder**, distinct from the glandular dysfunction seen in sicca syndrome. *Chronic active hepatitis* - **Primary biliary cholangitis** (formerly primary biliary cirrhosis), a form of chronic active hepatitis, is strongly associated with sicca syndrome. Patients often experience dry eyes and mouth alongside liver involvement. - Autoimmune hepatitis can also present with **extraglandular manifestations** including sicca symptoms, highlighting a systemic autoimmune link. *Rheumatoid arthritis* - **Secondary Sjögren's syndrome**, which manifests as sicca symptoms, commonly occurs in patients with **rheumatoid arthritis (RA)**. This is a well-recognized overlap. - The inflammatory processes common to both conditions suggest a shared **autoimmune pathogenesis**. *Scleroderma* - **Systemic sclerosis (scleroderma)** is another autoimmune connective tissue disease that frequently overlaps with Sjögren's syndrome and features of sicca [1]. - Patients with scleroderma often report **dry eyes and mouth**, reflecting autoimmune involvement of the exocrine glands.

Q: Which is the best investigation to confirm diagnosis of anaphylaxis?

Serum tryptase. ***Serum tryptase*** - **Serum tryptase** is released from activated mast cells and is a reliable biomarker for confirming anaphylaxis, particularly when measured within 1-3 hours of symptom onset. - Elevated levels help differentiate anaphylaxis from other conditions with similar symptoms, especially when the clinical picture is ambiguous. *IgA levels* - **IgA levels** are relevant in diagnosing conditions like selective IgA deficiency or celiac disease, but they do not play a direct role in confirming acute anaphylaxis. - They reflect long-term immune status rather than immediate hypersensitivity reactions. *IgD levels* - **IgD levels** have no established role in the diagnosis or confirmation of anaphylaxis. - Their physiological function is not fully understood, but they are not used as biomarkers for acute allergic reactions. *Serum precipitins* - **Serum precipitins** are antibodies detected in various hypersensitivity reactions, especially to inhaled antigens, and are not specific for anaphylaxis [1]. - They are primarily associated with conditions like hypersensitivity pneumonitis, reflecting different immunological mechanisms [1].

Q: Raynaud's phenomenon seen in all EXCEPT:

Juvenile rheumatoid arthritis. ***Juvenile rheumatoid arthritis*** - While other **rheumatic conditions** are often associated with Raynaud's phenomenon, **juvenile idiopathic arthritis (JIA)**, including the category once known as **juvenile rheumatoid arthritis**, is generally not a common cause [2]. - Its pathophysiology primarily involves **joint inflammation** rather than **vasospastic disorders**. *Scleroderma* - Raynaud's phenomenon is a **hallmark symptom** in nearly all patients with **scleroderma**, often preceding other symptoms by years [3]. - It results from **fibrosis and structural changes** in small blood vessels, leading to exaggerated vasoconstriction [3]. *SLE* - **Systemic lupus erythematosus (SLE)** is frequently associated with Raynaud's phenomenon, occurring in about 20-30% of patients [1]. - It is part of the broader **vasculopathy** seen in autoimmune diseases. *Dermatomyositis* - Raynaud's phenomenon can occur in patients with **dermatomyositis**, though less frequently than in scleroderma (around 15-20%). - Its presence often indicates a more complex **autoimmune overlap syndrome**.

Q: HLA B27 is associated with all except: a) Ankylosing spondylitis b) Pernicious anemia c) Behcet's syndrome d) Reiter's syndrome

Behcet's syndrome. ***Behcet's syndrome*** - While Behcet's syndrome is an inflammatory condition, it is **not typically associated with HLA-B27**. It is more commonly linked to **HLA-B51**. - Its clinical presentation involves recurrent oral and genital ulcers, uveitis, and skin lesions, which are distinct from the spondyloarthritis spectrum. *Ankylosing spondylitis* - This is a classic **HLA-B27 associated spondyloarthropathy**, characterized by chronic inflammation of the sacroiliac joints and spine [1]. - The presence of HLA-B27 significantly increases susceptibility to this condition. *Reiter's syndrome* - Now more commonly referred to as **Reactive Arthritis**, this condition is strongly associated with **HLA-B27** [1]. - It often presents with a triad of arthritis, urethritis, and conjunctivitis following a genitourinary or gastrointestinal infection. *Psoriatic arthritis* - While not as strongly linked as ankylosing spondylitis or reactive arthritis, about **30-50% of patients with psoriatic arthritis test positive for HLA-B27**, especially those with spinal involvement [1]. - It is an inflammatory arthritis associated with **psoriasis** and can affect peripheral joints, the spine, and entheses.

Q: "Telescope fingers" occur in

Psoriatic arthritis. ### Psoriatic arthritis - **Telescoping fingers**, also known as **arthritis mutilans**, is a severe and rare form of psoriatic arthritis where bone resorption leads to shortening and collapse of digits [1]. - This extreme joint erosion and destruction result in the characteristic "opera glass" or "telescopic" appearance of the fingers and toes [1]. *Reiter's arthritis* - Reiter's arthritis, now known as **reactive arthritis**, is characterized by the triad of **urethritis**, **arthritis**, and **conjunctivitis**. - While it can cause dactylitis ("sausage digits"), it does not typically lead to the severe bone resorption and telescoping seen in arthritis mutilans. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease that can develop after a Group A Streptococcus infection, primarily affecting the heart, joints, brain, and skin. - It causes a **migratory polyarthritis** that is typically acute and self-limiting, without permanent joint damage or deformities like telescoping fingers. *Rheumatoid arthritis* - **Rheumatoid arthritis** is a chronic inflammatory autoimmune disease primarily affecting the synovial lining of joints, leading to painful swelling, bone erosion, and joint deformity. - While it can cause severe joint destruction and deformities like **swan-neck** and **boutonnière** deformities, true "telescoping fingers" (arthritis mutilans) are not characteristic of rheumatoid arthritis.

Q: An elderly male presents with pain in his shoulders and hands. ESR is 105 mm/L. History includes transient blindness and unilateral headache.

Polymyalgia rheumatica. ***Polymyalgia rheumatica*** - The combination of **shoulder and hand pain** in an elderly male, along with a **very high ESR**, is highly suggestive of polymyalgia rheumatica [1]. - **Sudden transient blindness** and **unilateral headache** are concerning for giant cell arteritis, which is often associated with polymyalgia rheumatica and requires prompt treatment. *Polyarteritis nodosa* - This is a **necrotizing vasculitis** of medium-sized arteries, often presenting with systemic symptoms, **renal involvement**, and **neuropathy**. - It typically does not cause shoulder and hand pain as the primary presenting symptom, and the transient blindness and headache are more characteristic of giant cell arteritis. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton**, causing **inflammatory back pain** and stiffness, particularly in younger individuals [2]. - It does not typically present with shoulder and hand pain, transient blindness, or a temporal headache in an elderly patient. *Behçet syndrome* - Characterized by **recurrent oral and genital ulcers**, **uveitis**, and **skin lesions**. - The presenting symptoms of shoulder and hand pain, high ESR, transient blindness, and unilateral headache are not typical features of Behçet syndrome.

Q: Which of the following is a 'Small Vessel Vasculitis':

Microscopic polyangitis. ***Microscopic polyangitis*** - This is a form of **ANCA-associated vasculitis** that primarily affects **small vessels** (capillaries, venules, and arterioles) [1]. - It is characterized by **necrotizing vasculitis** within these small vessels, often presenting with features like **glomerulonephritis** and **pulmonary hemorrhage** [1]. *Takayasu's Disease* - This is a **large vessel vasculitis** that primarily affects the **aorta** and its major branches [1]. - It often presents with symptoms related to **ischemia** in the upper limbs or head, such as claudication or syncope. *Polyaeritis Nodosa (PAN)* - This is a **medium-sized vessel vasculitis** that typically spares capillaries, venules, and arterioles, distinguishing it from small vessel vasculitis [1]. - It classically presents as a **necrotizing vasculitis** affecting multiple organs, often without affecting the lungs or glomeruli significantly. *Giant cell vasculitis* - Also known as **Temporal Arteritis**, this is a **large vessel vasculitis** affecting the aorta and its major branches, particularly the branches of the **carotid artery** [1]. - It is characterized by the presence of **giant cells** in the inflamed vessel wall and is a common cause of **headache**, **jaw claudication**, and **vision loss** in older adults.

Q: All of the following are found in SLE except

Leucocytosis. ***Leucocytosis*** - **Leucopenia** (decreased white blood cell count) is a common hematological manifestation in SLE, not **leucocytosis**. - A persistent white blood cell count of **less than 4,000/mm³** on two or more occasions in the absence of other causes is a criterion for SLE. *Psychosis* - **Neuropsychiatric manifestations**, including psychosis, are recognized as a serious complication of SLE, categorized under **neuropsychiatric SLE (NPSLE)**. - These symptoms result from **inflammation, autoantibody production**, and other immune-mediated processes affecting the central nervous system [1]. *Oral ulcers* - **Oral or nasopharyngeal ulcers** are a common mucocutaneous manifestation of SLE. - These ulcers are typically **painless** and can be found on the **hard palate** or buccal mucosa. *Discoid rash* - A **discoid rash** is a specific skin manifestation of cutaneous lupus, often chronic and causing scarring [1]. - It presents as **erythematous raised patches with adherent keratotic scaling** and follicular plugging, which can lead to scarring alopecia [1].

Q: Antibody in drug induced Lupus

Anti-Histone. ***Anti-Histone*** - **Anti-histone antibodies** are present in 95% of patients with **drug-induced lupus erythematosus (DILE)**, making them the most characteristic serological marker. - They target nuclear proteins (histones) and are crucial for diagnosing DILE. *Anti-smith* - **Anti-Smith antibodies** are highly specific for **systemic lupus erythematosus (SLE)** [1], but not typically associated with drug-induced forms. - Their presence helps distinguish SLE from other autoimmune conditions and drug-induced reactions [1]. *Anti-phospholipid* - **Anti-phospholipid antibodies** are associated with **Antiphospholipid Syndrome (APS)**, an autoimmune disorder causing thrombosis and recurrent pregnancy loss [1]. - While they can be found in a minority of SLE patients, they are not specific to DILE [1]. *Anti-Ribosomal* - **Anti-ribosomal P antibodies** are often found in patients with **SLE**, particularly those with associated **neuropsychiatric symptoms** or **renal involvement**. - They are not a hallmark of drug-induced lupus and are more indicative of idiopathic SLE.

Question 1

Sicca syndrome is associated with all except?

Accepted Answer

Midline granuloma

Answer

Chronic active hepatitis

Answer

Rheumatoid arthritis

Answer

Scleroderma

Question 2

Which is the best investigation to confirm diagnosis of anaphylaxis?

Accepted Answer

Serum tryptase

Answer

IgA levels

Answer

IgD levels

Answer

Serum precipitins

Question 3

Raynaud's phenomenon seen in all EXCEPT:

Accepted Answer

Juvenile rheumatoid arthritis

Answer

Scleroderma

Answer

SLE

Answer

Dermatomyositis

Question 4

HLA B27 is associated with all except:
a) Ankylosing spondylitis
b) Pernicious anemia
c) Behcet's syndrome
d) Reiter's syndrome

Accepted Answer

Behcet's syndrome

Answer

Ankylosing spondylitis

Answer

Reiter's syndrome

Answer

Psoriatic arthritis

Question 5

Which is a minor criterion for diagnosis of RF according to modified Jones criteria?

Accepted Answer

Fever

Answer

Past History of Rheumatic Fever

Answer

Subcutaneous nodules

Answer

ASO titre

Question 6

"Telescope fingers" occur in

Accepted Answer

Psoriatic arthritis

Answer

Reiter's arthritis

Answer

Rheumatic fever

Answer

Rheumatoid arthritis

Question 7

An elderly male presents with pain in his shoulders and hands. ESR is 105 mm/L. History includes transient blindness and unilateral headache.

Accepted Answer

Polymyalgia rheumatica

Answer

Polyarteritis nodosa

Answer

Ankylosing spondylitis

Answer

Behçet syndrome

Question 8

Which of the following is a 'Small Vessel Vasculitis':

Accepted Answer

Microscopic polyangitis

Answer

Takayasu's Disease

Answer

Polyaeritis Nodosa (PAN)

Answer

Giant cell vasculitis

Question 9

All of the following are found in SLE except

Accepted Answer

Leucocytosis

Answer

Psychosis

Answer

Discoid rash

Answer

Oral ulcers

Question 10

Antibody in drug induced Lupus

Accepted Answer

Anti-Histone

Answer

Anti-smith

Answer

Anti-phospholipid

Answer

Anti-Ribosomal

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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