Rheumatology and Immunology Practice Questions

Q: Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?

Symmetrical muscle weakness.. ***Symmetrical muscle weakness.*** - **Muscle weakness** is not a primary diagnostic criterion for **rheumatoid arthritis (RA)** [1]. While muscle atrophy can occur secondary to chronic inflammation and disuse, it's not a defining feature used in diagnostic classification. Symmetrical proximal muscle weakness is instead a hallmark of conditions like polymyositis [2]. - The diagnostic criteria focus on **inflammatory arthritis**, joint involvement patterns, serological markers, and acute phase reactants [1]. *Raised rheumatoid factor.* - The presence of **rheumatoid factor (RF)**, especially in high titers, is a key serological marker for RA, included in the diagnostic criteria [1]. - While not exclusive to RA, its presence aids in confirming the diagnosis, particularly in conjunction with clinical symptoms. *Symmetric swelling (arthritis) for at least 6 weeks.* - **Symmetric polyarthritis**, particularly affecting the **small joints** of the hands and feet, is a hallmark clinical presentation of RA and a central diagnostic criterion [1], [3]. - The **duration of at least 6 weeks** helps differentiate RA from transient or acute forms of arthritis [1]. *Rheumatoid nodules.* - **Rheumatoid nodules**, subcutaneous swellings typically found over bony prominences, are a characteristic extra-articular manifestation of RA and are included [4]. - Their presence indicates more severe disease and is highly specific for RA [4].

Q: Sjogren's syndrome includes all except:

Lymphoma. Sjogren's syndrome includes all except: ***Lymphoma*** - While patients with **Sjogren's syndrome** have a significantly **increased risk of developing lymphoma** (particularly MALT lymphoma), lymphoma itself is not considered one of the primary diagnostic features or components of the syndrome. - Sjogren's syndrome is an **autoimmune disease** characterized by immune-mediated destruction of exocrine glands, leading to sicca symptoms. *Keratoconjunctivitis* - This is a hallmark feature of Sjogren's syndrome, referring to **dry eyes** due to reduced lacrimal gland function. - The sensation of **gritty eyes** or foreign body sensation is common. *Xerostomia* - This symptom, commonly known as **dry mouth**, is a classic manifestation of Sjogren's syndrome resulting from inflammation and damage to the salivary glands. - Patients often report difficulty chewing, swallowing, and speaking. *Arthritis* - **Arthralgia** (joint pain) and **non-erosive arthritis** are common systemic manifestations observed in patients with Sjogren's syndrome. - This joint involvement is typically **symmetrical** and affects the small joints, similar to rheumatoid arthritis but usually without the destructive changes.

Q: A 34-year-old woman has Raynaud's phenomenon associated with systemic sclerosis (scleroderma). Which of the following is the most appropriate management for this condition?

warm clothing. ***Warm clothing*** - Maintaining **core body temperature** and direct protection of extremities from **cold exposure** is the primary non-pharmacological management for Raynaud's phenomenon. - This helps prevent the **vasospasm** triggered by cold, reducing the frequency and severity of attacks. *ergotamine* - **Ergotamine** is a powerful **vasoconstrictor** and would worsen Raynaud's phenomenon by further narrowing blood vessels. - It is primarily used for **migraine treatment** and is contraindicated in conditions involving vasoconstriction. *calcium channel blockers (nifedipine)* - While **calcium channel blockers** like nifedipine are often used as **second-line pharmacological treatment** for Raynaud's, warm clothing represents a more fundamental and universally applicable management strategy. [1] - Nifedipine works by causing **vasodilation**, which can reduce the severity and frequency of attacks when non-pharmacological methods are insufficient. [1] *beta-blocking drugs* - **Beta-blockers** can worsen Raynaud's phenomenon by causing **vasoconstriction** due to unopposed alpha-adrenergic activity. [1] - These drugs are generally **contraindicated** in patients with Raynaud's syndrome. [1]

Q: Which of the following manifestation of rheumatic fever disappears completely?

Arthritis. Arthritis - **Arthritis** in rheumatic fever is typically migratory, affecting large joints, and is self-limiting, resolving completely without chronic damage. - It is one of the **major Jones criteria** but usually leaves no residual joint deformity or functional impairment. *Chorea* - **Sydenham's chorea**, also known as **St. Vitus' dance**, can persist for several weeks or months and may **recur in about one-third of patients**, though it often resolves completely over time [1]. - While it typically resolves, some patients may experience subtle neurological or psychological sequelae. *Carditis* - **Carditis** is the most serious manifestation of rheumatic fever and can lead to **permanent valvular damage**, known as **rheumatic heart disease** [1], [2]. - It often results in **chronic cardiovascular complications** that do not disappear completely [2]. *Subcutaneous nodules* - **Subcutaneous nodules** are typically firm, painless lesions that appear over bony prominences. - While they usually **resolve within weeks**, they are a sign of severe rheumatic fever and can be associated with more serious complications like carditis, indicating a more significant inflammatory process.

Q: Which of the following auto antibodies is most likely to be present in a patient with systemic lupus erythematosus?

Anti- ds DNA. ***Anti-ds DNA*** - **Anti-double-stranded DNA (anti-dsDNA)** antibodies are highly specific for **Systemic Lupus Erythematosus (SLE)** and are included in the classification criteria [1]. - Their levels often correlate with disease activity, especially in cases with **lupus nephritis** [1]. *Antiphospholipid* - While **antiphospholipid antibodies** can be present in SLE patients (leading to **secondary antiphospholipid syndrome**), they are not the most characteristic or diagnostic autoantibody for SLE itself. - These antibodies are primarily associated with a **prothrombotic state** and recurrent miscarriages. *Anti-Ro* - **Anti-Ro (SSA) antibodies** are associated with SLE, particularly with **cutaneous lupus**, **neonatal lupus**, and **Sjögren's syndrome**, but they are not as specific as anti-dsDNA for the general diagnosis of SLE [1]. - Patients with anti-Ro antibodies may have a higher risk of **photosensitivity** [1]. *Anti-RNP* - **Anti-RNP antibodies** are found in patients with SLE, but they are most characteristically associated with **Mixed Connective Tissue Disease (MCTD)**. - Their presence in SLE often correlates with less severe renal involvement but may indicate **myositis** or **Raynaud's phenomenon**.

Q: A 26-year-old pregnant woman presents with arthritis and a malar rash that worsens with sun exposure. She has a low-grade fever and is admitted to the hospital. What is the likely diagnosis?

Systemic Lupus Erythematosus. ***Systemic Lupus Erythematosus*** - The combination of **arthritis**, **malar rash** that worsens with sun exposure (photosensitivity), and a **low-grade fever** in a young woman is highly characteristic of systemic lupus erythematosus (SLE) [1]. - SLE is an **autoimmune disease** with diverse clinical manifestations affecting multiple organ systems [1]. *Lyme disease* - Characterized by a **target-like rash (erythema migrans)**, which is distinct from a malar rash, and often presents with flu-like symptoms. - While Lyme disease can cause arthritis, the presence of a classic malar rash and photosensitivity points away from this diagnosis. *Chloasma* - Also known as the **"mask of pregnancy,"** chloasma is a common skin condition in pregnant women causing dark, discolored patches on the face. - It is a **pigmentation disorder** and does not involve arthritis, fever, or an associated malar rash that worsens with sun exposure. *Steven Johnsons syndrome* - An infrequent, serious systemic reaction to medication or infection, that triggers severe skin and mucous membrane reactions, typically presenting with **widespread blistering** and epidermal detachment. - This is an **acute, severe mucocutaneous reaction** and does not present with the chronic arthritis and photosensitive malar rash seen in this patient.

Q: ANA (antinuclear antibody) is seen in all except:

RA. ***RA*** - While ANA can be positive in a small percentage of RA patients, it is **not a characteristic feature** of rheumatoid arthritis and is found in only 30–50% of cases [1]. - The primary diagnostic markers for RA are **rheumatoid factor (RF)** and **anti-citrullinated protein antibody (ACPA)**. *Systemic sclerosis* - **Antinuclear antibodies (ANA)** are present in over 90% of patients with systemic sclerosis, often with specific patterns like nucleolar or centromere [1]. - This makes ANA a key diagnostic and classification criterion for the disease. *Sjogren's syndrome* - **ANA is positive in 80-90%** of patients with Sjögren's syndrome, making it a very common finding [1]. - Specific autoantibodies like anti-Ro (SSA) and anti-La (SSB) are also frequently present alongside ANA [1]. *SLE* - **ANA is highly sensitive for SLE**, being positive in over 95% of patients with systemic lupus erythematosus [1]. - A negative ANA virtually rules out SLE, making it a crucial screening test [2].

Q: A 50-year-old male patient presented with weakness of bilateral lower limbs which was symmetrical (distal weakness >> proximal muscle weakness) for 1 month. On examination, certain skin and nail changes were noted. Patient also complained of myalgia and arthralgia. Lab findings: Raised creatinine kinase levels, Raised ANA antibody titre. Muscle biopsy was done from the quadriceps femoris muscle. CD4+ cells were found in the cellular infiltrate. IHC study of which protein is a very sensitive diagnostic test for the above condition?

Myxovirus resistance protein. ***Myxovirus resistance protein*** - The clinical presentation suggests **dermatomyositis** or **polymyositis**, characterized by symmetrical muscle weakness, skin/nail changes, myalgia, arthralgia, and elevated CK/ANA [1]. - In these conditions, **Type I interferon (IFN-I)** activation occurs, leading to increased expression of **myxovirus resistance protein A (MxA)**, which serves as a highly sensitive biomarker. *Adenovirus resistance protein* - This is not a recognized or specific biomarker for **inflammatory myopathies** like dermatomyositis or polymyositis. - While adenoviruses can cause muscle inflammation in certain contexts, related resistance proteins are not used for diagnosis in this manner. *Parvovirus resistance protein* - Parvovirus B19 can cause myositis, but "parvovirus resistance protein" is not a specific or sensitive diagnostic marker for **idiopathic inflammatory myopathies**. - The associated immune response and biomarkers would relate more directly to the viral infection itself. *Papovavirus resistance protein* - **Papovaviruses** (e.g., human papillomavirus, JC virus) are not typically associated with **idiopathic inflammatory myopathies**. - There is no "papovavirus resistance protein" that serves as a diagnostic biomarker for the presented clinical picture.

Q: Which of the following is not an extra-articular feature of Rheumatoid arthritis?

Proteinuria. ***Proteinuria*** - While kidney involvement can occur in RA (e.g., secondary amyloidosis, drug-induced nephropathy), **proteinuria** itself is not a direct or typical extra-articular feature of rheumatoid arthritis [1]. - It usually indicates a **complication** or secondary condition rather than a primary manifestation of RA. *Conjunctivitis* - **Sjögren's syndrome**, often associated with RA, can cause **dry eyes** (keratoconjunctivitis sicca), which may be described as conjunctivitis-like symptoms [1]. - **Episcleritis** and **scleritis** are also known ocular manifestations of RA, though less common than dry eyes [1]. *Pleural effusion* - **Rheumatoid pleurisy** leading to pleural effusion is a recognized extra-articular manifestation, often characterized by **low glucose levels** in the pleural fluid. - It can be symptomatic (e.g., chest pain, dyspnea) or asymptomatic. *Weight loss* - **Systemic inflammation** and the catabolic state associated with active RA can lead to generalized **fatigue** and **unintentional weight loss** [1]. - This is a common non-specific extra-articular symptom reflecting disease activity.

Q: Autoimmune diseases associated with Sjögren syndrome are all except?

Addison's disease. ***Addison's disease*** - While an **autoimmune disorder** itself (involving the adrenal glands), Addison's disease is generally **not directly associated** as a co-occurring autoimmune condition with Sjögren's syndrome. - Sjögren's syndrome is primarily characterized by **exocrine gland dysfunction**, specifically affecting lacrimal and salivary glands. *RA* - **Rheumatoid arthritis (RA)** is one of the most common autoimmune diseases found in association with **secondary Sjögren's syndrome**. - Sjögren's syndrome can occur in approximately **10-15% of patients with RA**, highlighting a strong pathogenic link. *SLE* - **Systemic lupus erythematosus (SLE)** frequently coexists with Sjögren's syndrome, often making it challenging to differentiate primary from secondary Sjögren's. - Both conditions share common **autoimmune mechanisms** and autoantibody profiles (e.g., anti-Ro/SSA and anti-La/SSB antibodies). *Mixed connective tissue disorder* - **Mixed connective tissue disease (MCTD)** is characterized by overlapping features of SLE, systemic sclerosis, and polymyositis, and also frequently includes features of **Sjögren's syndrome**. - The presence of **anti-U1-RNP antibodies** is a hallmark of MCTD, and these patients often experience sicca symptoms.

Question 1

Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?

Accepted Answer

Symmetrical muscle weakness.

Answer

Raised rheumatoid factor.

Answer

Symmetric swelling (arthritis) for at least 6 weeks.

Answer

Rheumatoid nodules.

Question 2

Sjogren's syndrome includes all except:

Accepted Answer

Lymphoma

Answer

Keratoconjunctivitis

Answer

Xerostomia

Answer

Arthritis

Question 3

A 34-year-old woman has Raynaud's phenomenon associated with systemic sclerosis (scleroderma). Which of the following is the most appropriate management for this condition?

Accepted Answer

warm clothing

Answer

ergotamine

Answer

calcium channel blockers (nifedipine)

Answer

beta-blocking drugs

Question 4

Which of the following manifestation of rheumatic fever disappears completely?

Accepted Answer

Arthritis

Answer

Chorea

Answer

Carditis

Answer

Subcutaneous nodules

Question 5

Which of the following auto antibodies is most likely to be present in a patient with systemic lupus erythematosus?

Accepted Answer

Anti- ds DNA

Answer

Antiphospholipid

Answer

Anti-Ro

Answer

Anti-RNP

Question 6

A 26-year-old pregnant woman presents with arthritis and a malar rash that worsens with sun exposure. She has a low-grade fever and is admitted to the hospital. What is the likely diagnosis?

Accepted Answer

Systemic Lupus Erythematosus

Answer

Lyme disease

Answer

Chloasma

Answer

Steven Johnsons syndrome

Question 7

ANA (antinuclear antibody) is seen in all except:

Accepted Answer

RA

Answer

Systemic sclerosis

Answer

Sjogren's syndrome

Answer

SLE

Question 8

A 50-year-old male patient presented with weakness of bilateral lower limbs which was symmetrical (distal weakness >> proximal muscle weakness) for 1 month. On examination, certain skin and nail changes were noted. Patient also complained of myalgia and arthralgia. Lab findings: Raised creatinine kinase levels, Raised ANA antibody titre. Muscle biopsy was done from the quadriceps femoris muscle. CD4+ cells were found in the cellular infiltrate. IHC study of which protein is a very sensitive diagnostic test for the above condition?

Accepted Answer

Myxovirus resistance protein

Answer

Adenovirus resistance protein

Answer

Parvovirus resistance protein

Answer

Papovavirus resistance protein

Question 9

Which of the following is not an extra-articular feature of Rheumatoid arthritis?

Accepted Answer

Proteinuria

Answer

Conjunctivitis

Answer

Pleural effusion

Answer

Weight loss

Question 10

Autoimmune diseases associated with Sjögren syndrome are all except?

Accepted Answer

Addison's disease

Answer

RA

Answer

SLE

Answer

Mixed connective tissue disorder

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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