Rheumatology and Immunology Practice Questions

Q: Which joint is LEAST commonly affected in early rheumatoid arthritis?

Tarsometatarsal. ***Tarsometatarsal*** - The **tarsometatarsal joints** (Lisfranc joints) are deep within the foot and are relatively protected, making them less commonly involved in early RA. - While other foot joints like the metatarsophalangeal joints are frequently affected, the tarsometatarsals typically show involvement only in **advanced or severe disease**. *Knee* - The knee is a **large weight-bearing joint** that can be affected in RA but is less frequently involved in the **very early stages** compared to smaller joints [1]. - Though not a primary initial target, **synovitis and effusions** can develop as the disease progresses. *Ankle* - The ankle joint can be involved in RA, but it is **less common than the small joints of the hands and feet** in early disease [1]. - When affected, it typically presents with **pain, swelling, and stiffness**, impacting gait. *Metatarsophalangeal* - The **metatarsophalangeal (MTP) joints** are very commonly affected in early rheumatoid arthritis due to their synovial lining and frequent use [1]. - Involvement here often leads to **pain, swelling, and difficulty walking**, being a significant diagnostic criterion [2].

Q: Which of the following is not a primary symptom of Sjögren's syndrome?

Systemic manifestations. ***Systemic manifestations*** - While Sjögren's syndrome can have **systemic manifestations**, they are secondary complications or features, not among the **primary, defining symptoms** that establish the diagnosis. - The primary symptoms directly relate to **exocrine gland dysfunction**, specifically lacrimal and salivary glands. *Dry eyes* - This is a cardinal symptom, resulting from damage to the **lacrimal glands** leading to decreased tear production. - Patients typically report a **gritty or burning sensation** in their eyes. *Dry mouth* - Another core symptom, resulting from dysfunction of the **salivary glands** and reduced saliva flow. - This can lead to difficulties in **speaking, swallowing**, increased dental carries, and oral discomfort. *Parotid gland enlargement* - This is a common and often **visible clinical sign** of Sjögren's syndrome, indicating inflammation of the **major salivary glands**. - It results from lymphocytic infiltration and is typically recurrent or persistent.

Q: A 64-year-old man presents to the clinic with generalized weakness, difficulty getting out of a chair and lifting objects above his head, and a 15-pound weight loss. He has a blue-purple rash on his eyelids and knuckles, and his proximal muscle strength is rated 4 out of 5. Laboratory investigations reveal an elevated creatinine kinase (CK) level. He is started on prednisone therapy. Which of the following is the most important in monitoring response to therapy?

testing of muscle strength. ***testing of muscle strength*** - **Proximal muscle weakness** (difficulty getting out of a chair and lifting objects) is a primary symptom of **dermatomyositis**, which is indicated by the rash and elevated CK [1]. - Monitoring improvement in **muscle strength** directly reflects the patient's functional recovery and response to prednisone, making it the most critical measure [3]. *sedimentation rates* - **Erythrocyte sedimentation rate (ESR)** can be elevated in inflammatory conditions but is a **non-specific marker** of inflammation [2]. - It does not directly correlate with muscle damage or recovery in dermatomyositis, making it less useful for monitoring therapeutic response. *serum muscle enzymes (CK)* - Elevated **creatinine kinase (CK)** levels indicate muscle damage, and while typically elevated in active disease, CK levels can take time to normalize even with effective treatment [2]. - Clinical improvement in **muscle strength** often precedes the complete normalization of CK levels, making functional assessment more immediately relevant for therapeutic adjustments. *EMG* - **Electromyography (EMG)** is a diagnostic tool used to confirm muscle involvement and differentiate myopathic from neuropathic conditions [2]. - While useful for initial diagnosis, it is **not routinely used** for monitoring treatment response due to its invasive nature and lack of direct correlation with daily functional improvement.

Q: Mask-like appearance of the face, narrowing of the aperture, and rigidity of the mucosa are characteristic of:

Progressive systemic sclerosis. ### Progressive systemic sclerosis - This condition is characterized by **fibrosis** of the skin and internal organs, leading to the **mask-like appearance** of the face due to skin tightening [1]. - The **narrowing of the oral aperture** (microstomia) and **rigidity of the oral mucosa** are also common manifestations due to collagen deposition [1]. *Tetanus* - Tetanus causes muscle spasms and rigidity, notably **trismus** (lockjaw) which is a forceful closing of the jaw, not a narrowing of the opening itself. - It does not cause a mask-like facial appearance or characteristic mucosal rigidity but rather strong, painful muscle contractions. *Multiple sclerosis* - This is a **demyelinating disease** affecting the central nervous system, leading to neurological symptoms like motor weakness, sensory disturbances, and vision problems. - It does not involve the characteristic facial or oral changes described in the question. *Osteomalacia* - This condition involves **defective bone mineralization** due to vitamin D deficiency, leading to bone pain and muscle weakness. - It primarily affects the skeletal system and does not cause facial changes or mucosal rigidity.

Q: Butterfly rash is associated with:

SLE. ***SLE*** - **Systemic lupus erythematosus (SLE)** is characterized by a classic malar rash, also known as a **butterfly rash**, which spares the nasolabial folds [1]. - This rash is a common cutaneous manifestation of **SLE** and is one of the diagnostic criteria [1]. *DLE* - **Discoid lupus erythematosus (DLE)** primarily affects the skin, causing scarring lesions, but it does not typically present as a widespread malar or **butterfly rash** [1]. - DLE lesions are usually chronic, well-demarcated, and can lead to **atrophy** and **permanent scarring** [1]. *Rheumatoid arthritis* - **Rheumatoid arthritis** is an inflammatory arthritis primarily affecting the **synovial joints**, leading to joint destruction. - It does not present with a **butterfly rash**; skin manifestations, if present, are usually rheumatoid nodules or vasculitis. *Reiter's syndrome* - **Reiter's syndrome**, now known as **reactive arthritis**, is characterized by a triad of arthritis, urethritis, and conjunctivitis. - It is often triggered by an infection and does not involve a **butterfly rash**; skin findings may include **circinate balanitis** or keratoderma blennorrhagicum.

Q: In which of the following conditions is joint erosion NOT a primary feature?

SLE. ***SLE*** - While arthritis is common in **Systemic Lupus Erythematosus (SLE)**, it is typically **non-erosive**, meaning it does not cause damage to the **cartilage** or **bone** [1]. - Joint involvement in SLE is often characterized by **arthralgias** or a **reversible inflammatory arthritis**. *Osteoarthritis* - **Osteoarthritis** is definitively characterized by the **progressive erosion of articular cartilage**, leading to **bone-on-bone friction** and structural changes. - This condition involves **wear-and-tear** that directly causes damage to the joint surfaces. *Psoriatic arthropathy* - **Psoriatic arthropathy** (Psoriatic Arthritis) is an inflammatory condition that can lead to significant **joint erosion** and **destruction**, particularly in the small joints of the hands and feet [1]. - It often features characteristic radiographic changes such as **"pencil-in-cup" deformities** due to bone resorption and erosion [1]. *Rheumatoid arthritis* - **Rheumatoid arthritis** is a classic example of an inflammatory arthritis where **joint erosion** is a primary and hallmark feature, driven by **synovial inflammation** and pannus formation. - Persistent inflammation in RA leads to **cartilage destruction** and **subchondral bone erosion**.

Q: Heberden's arthropathy affects:

Distal interphalangeal joint. ***Distal interphalangeal joint*** - **Heberden's nodes** are pathognomonic bony enlargements that occur on the **distal interphalangeal (DIP) joints** of the fingers [1]. - They are a classic sign of **osteoarthritis**, resulting from cartilage degeneration and new bone formation [1]. *Lumbar spine involvement* - While osteoarthritis can affect the **lumbar spine**, it presents as **back pain** and stiffness, not as nodules on the fingers [1]. - **Heberden's nodes** are specifically associated with peripheral joint involvement, not axial skeleton [1]. *Sacroiliac joint involvement* - **Sacroiliac joint involvement** is characteristic of **spondyloarthropathies** like ankylosing spondylitis, causing inflammatory back pain [1]. - It does not present with bony nodes on the fingers, which are typical of osteoarthritic changes [1]. *Knee joint involvement* - **Knee joint involvement** is common in osteoarthritis, causing pain, swelling, and reduced range of motion [1]. - However, **Heberden's nodes** are distinct from knee symptoms and refer specifically to changes in the DIP joints [1].

Q: All of the following conditions are associated with raised ANCA, except:

Polyarteritis Nodosa. ***Polyarteritis Nodosa*** - Polyarteritis Nodosa is not typically associated with **positive ANCA** (Anti-Neutrophil Cytoplasmic Antibodies) and is mainly characterized by systemic vasculitis affecting medium-sized arteries. [1] - This condition usually presents with symptoms like **weight loss**, **fever**, and **muscle pain**, without the underlying ANCA association. [1] *Wegener's granulomatosis* - Also known as Granulomatosis with Polyangiitis, this condition is strongly associated with **c-ANCA** positivity, often targeting **proteinase 3**. - Clinical features include **respiratory symptoms** and renal involvement, particularly **glomerulonephritis**. *Microscopic Polyangitis* - This vasculitis is associated with **p-ANCA** positivity, commonly targeting **myeloperoxidase** (MPO). - It frequently presents with **pulmonary hemorrhage** and **renal vasculitis**. *Churg-Strauss syndrome* - Known as Eosinophilic Granulomatosis with Polyangiitis, it is associated with **p-ANCA** and involves asthma, eosinophilia, and systemic vasculitis [2]. - Typical manifestations include **respiratory involvement** and peripheral neuropathy, further linking it to ANCA positivity.

Q: A 25-year-old male with a 2-week history of fever and malaise, arthritis of the ankle joint, and tender erythematous nodules over the shin is diagnosed with which condition?

Erythema nodosum. ***Erythema nodosum*** - Typically presents with **tender erythematous nodules** on the shins, consistent with the patient's symptoms [1]. - Often associated with **systemic conditions** causing fever and joint pain, like infections or autoimmune diseases. *Urticarial vasculitis* - Characterized by **hives** that last longer than 24 hours and are often itchy, not nodular. - Does not typically present with **arthritis** or nodules as seen in this case. *Erythema marginatum* - Presents with **ring-like lesions** that can appear during rheumatic fever, not nodular lesions on the shins. - Generally does not cause **arthritis** or systemic fever as primary features. *Weber-Christian disease* - Also known as **pyoderma gangrenosum**, it involves painful ulcers, not erythematous nodules or arthritis. - Characterized more by **systemic symptoms** and not specifically by the findings noted in this patient.

Q: Which of the following statements about rheumatoid arthritis is false?

Asymmetrical joint involvement. ***Asymmetrical joint involvement*** - **Rheumatoid arthritis** is classically characterized by **symmetrical polyarthritis**, affecting the same joints on both sides of the body [1]. - Asymmetrical involvement would be atypical and might suggest another form of inflammatory arthritis. *More common in females* - This statement is **true**; rheumatoid arthritis has a female-to-male predilection ratio of approximately 3:1 [2]. - The higher prevalence in females suggests a possible role of hormonal or genetic factors. *Elevated CRP* - This statement is **true**; an **elevated C-reactive protein (CRP)** level is a common finding in rheumatoid arthritis, indicating systemic inflammation [1]. - CRP, along with erythrocytic sedimentation rate (ESR), is used to monitor disease activity and treatment response [1]. *Associated with Felty's syndrome* - This statement is **true**; **Felty's syndrome** is a rare but severe complication of long-standing rheumatoid arthritis [2]. - It is characterized by the triad of **rheumatoid arthritis, splenomegaly, and neutropenia** [2].

Question 1

Which joint is LEAST commonly affected in early rheumatoid arthritis?

Accepted Answer

Tarsometatarsal

Answer

Knee

Answer

Ankle

Answer

Metatarsophalangeal

Question 2

Which of the following is not a primary symptom of Sjögren's syndrome?

Accepted Answer

Systemic manifestations

Answer

Parotid gland enlargement

Answer

Dry eyes

Answer

Dry mouth

Question 3

A 64-year-old man presents to the clinic with generalized weakness, difficulty getting out of a chair and lifting objects above his head, and a 15-pound weight loss. He has a blue-purple rash on his eyelids and knuckles, and his proximal muscle strength is rated 4 out of 5. Laboratory investigations reveal an elevated creatinine kinase (CK) level. He is started on prednisone therapy. Which of the following is the most important in monitoring response to therapy?

Accepted Answer

testing of muscle strength

Answer

sedimentation rates

Answer

EMG

Answer

serum muscle enzymes (CK)

Question 4

Mask-like appearance of the face, narrowing of the aperture, and rigidity of the mucosa are characteristic of:

Accepted Answer

Progressive systemic sclerosis

Answer

Tetanus

Answer

Multiple sclerosis

Answer

Osteomalacia

Question 5

Butterfly rash is associated with:

Accepted Answer

SLE

Answer

DLE

Answer

Reiter's syndrome

Answer

Rheumatoid arthritis

Question 6

In which of the following conditions is joint erosion NOT a primary feature?

Accepted Answer

SLE

Answer

Psoriatic arthropathy

Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Question 7

Heberden's arthropathy affects:

Accepted Answer

Distal interphalangeal joint

Answer

Lumbar spine involvement

Answer

Sacroiliac joint involvement

Answer

Knee joint involvement

Question 8

All of the following conditions are associated with raised ANCA, except:

Accepted Answer

Polyarteritis Nodosa

Answer

Wegener's granulomatosis

Answer

Microscopic Polyangitis

Answer

Churg-Strauss syndrome

Question 9

A 25-year-old male with a 2-week history of fever and malaise, arthritis of the ankle joint, and tender erythematous nodules over the shin is diagnosed with which condition?

Accepted Answer

Erythema nodosum

Answer

Erythema marginatum

Answer

Weber Christian disease

Answer

Urticarial vasculitis

Question 10

Which of the following statements about rheumatoid arthritis is false?

Accepted Answer

Asymmetrical joint involvement

Answer

More common in females

Answer

Elevated CRP

Answer

Associated with Fetty's syndrome

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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