Rheumatology and Immunology Practice Questions

Q: Tophi in gout found in all regions except -

Muscle. Muscle - **Tophi** are typically composed of **monosodium urate crystals** deposited in poorly vascularized tissues [1]. - While muscle can be affected in severe, chronic gout, it is an **atypical location** for primary tophaceous deposits compared to other listed structures. *Joint capsule* - The **joint capsule** is a common site for tophi formation, given its proximity to the affected joints and relatively **poor blood supply** compared to fully vascularized tissues [2]. - Deposits here contribute to **joint destruction** and inflammation [3]. *Articular cartilage* - **Articular cartilage** is avascular and a frequent site for **urate crystal deposition**, contributing to the **erosive changes** seen in chronic gout [1]. - These deposits can lead to **chondrocalcinosis-like features** and progressive joint damage. *Skin* - **Tophi** commonly form in the **subcutaneous tissue** of the skin, especially around the ears, fingers, toes, and elbows [2]. - They appear as **firm, whitish nodules** and are a hallmark of chronic tophaceous gout [2].

Q: In Raynaud's disease true is :

More common in female. ***More common in female*** - **Raynaud's phenomenon** is far more prevalent in **females**, particularly those between puberty and 40 years of age. - This **female predominance** is a key epidemiological feature, with an estimated female-to-male ratio as high as 9:1. *Sup. thrombophlebitis* - **Superficial thrombophlebitis** is the inflammation of a superficial vein due to a **blood clot**, which is not a typical manifestation or direct association of Raynaud's disease. - Raynaud's primarily involves **vasospasm** of small arteries, not thrombotic events in superficial veins. *Lower limb more commonly involved than upper limb* - **Raynaud's phenomenon** predominantly affects the **fingers and toes** (acral parts), with **upper limbs** being more commonly involved than the lower limbs, or at least equally, but not less. - Involvement of the **fingers** is the hallmark of the condition. *Associated with migraine* - While both **migraine** and **Raynaud's phenomenon** involve **vascular dysfunction** and are more prevalent in women, a direct, consistent, and causal association is not definitively established as a defining characteristic of Raynaud's disease itself. - Some studies suggest a higher comorbidity, but it isn't a universally true defining feature.

Q: Specific antibody for SLE is -

Anti ds DNA. ***Anti ds DNA*** - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are included in the diagnostic criteria. [1] - Their presence often correlates with **disease activity**, particularly with lupus nephritis. [1] *Anti-La* - **Anti-La (SS-B) antibodies** are primarily associated with Sjögren's Syndrome, though they can also be seen in SLE. [1] - They are considered a more specific marker for **Sjögren's Syndrome** than for SLE. *Anti-Jo* - **Anti-Jo-1 antibodies** are characteristic of **polymyositis** and dermatomyositis, particularly associated with interstitial lung disease in these conditions. - They are not typically found in SLE and are not a diagnostic marker for the disease. *Anti-Ro* - **Anti-Ro (SS-A) antibodies** are commonly found in Sjögren's Syndrome and are also associated with **subacute cutaneous lupus erythematosus (SCLE)** and neonatal lupus. [1] - While present in a significant percentage of SLE patients, they are not as specific as anti-dsDNA antibodies for the diagnosis of SLE itself. [1]

Q: Which one of the following conditions is not associated with rheumatoid arthritis? (If all are associated, select 'None').

None of the options. ***None of the options*** - All listed conditions—**cricoarytenoid arthritis**, **pleural effusion**, and **pulmonary hypertension**—are recognized extra-articular manifestations or complications of **rheumatoid arthritis (RA)** [1]. - Rheumatoid arthritis is a systemic inflammatory disease that can affect multiple organ systems beyond the joints. *Cricoarytenoid arthritis* - This condition involves inflammation of the **cricoarytenoid joint** in the larynx, leading to **hoarseness**, stridor, or even airway obstruction. - It is a known, though less common, upper airway manifestation of **rheumatoid arthritis**. *Pleural effusion* - **Rheumatoid pleuritis** commonly presents as a **pleural effusion**, often unilateral [1]. - Analysis of **rheumatoid pleural fluid** typically shows low glucose, high LDH, and sometimes rheumatoid factor. *Pulmonary hypertension* - **Pulmonary hypertension** in RA can result from various mechanisms, including **interstitial lung disease**, vasculitis, or chronic thromboembolism [1]. - It is a serious complication associated with increased morbidity and mortality in **rheumatoid arthritis** patients.

Q: A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?

Add Sulfasalazine. Focus on **Add Sulfasalazine**: - Since the patient has not responded to **Methotrexate** alone, adding a second conventional synthetic **disease-modifying antirheumatic drug (DMARD)** like **Sulfasalazine** is a common and appropriate step in a **treat-to-target strategy** for rheumatoid arthritis [1]. - This approach aims to achieve **disease remission** or **low disease activity** by combining therapies to enhance efficacy. *Continue Methotrexate and steroids at higher dose* - Increasing the dose of **Methotrexate** might be considered if the current dose is sub-optimal, but after 4 months with no improvement, simply continuing current medications at higher doses without adding another agent is less likely to significantly alter **disease progression** [1]. - Prolonged higher-dose **steroids** carry significant risks and are generally used for symptom control, not primary disease modification. *Stop oral Methotrexate and start parenteral Methotrexate* - Switching to **parenteral Methotrexate** is considered if **oral Methotrexate** absorption is an issue or if the patient experiences gastrointestinal side effects [1]. - While parenteral administration can improve bioavailability, it doesn't represent a change in therapeutic strategy for **uncontrolled disease activity**. *Start treatment with anti-TNF alpha drugs* - **Biologic DMARDs** like **anti-TNF alpha drugs** are typically reserved for patients who have failed **two or more conventional synthetic DMARDs**, including **Methotrexate**, or in cases of severe, rapidly progressing disease [2]. - While effective, they are more expensive and have different side effect profiles, making them a later-line treatment in the management algorithm [2].

Q: A 35-year-old woman with history of melanoma develops new-onset facial telangiectasias and sclerodactyly. ANA is positive. Most appropriate next step for staging is:

High-resolution chest CT. ***High-resolution chest CT*** - The patient's symptoms (telangiectasias, sclerodactyly, positive ANA) are highly suggestive of **systemic sclerosis (scleroderma)**, a connective tissue disease with significant pulmonary involvement [1]. - **Interstitial lung disease (ILD)**, a common and serious complication of systemic sclerosis, requires **high-resolution CT (HRCT)** for proper staging and monitoring. *Skin biopsy only* - While a skin biopsy might confirm cutaneous involvement of systemic sclerosis, it does not assess the crucial systemic complications, particularly pulmonary involvement. - It would therefore be insufficient for comprehensive staging in a patient with suspected scleroderma. *Echocardiogram with PFTs* - An **echocardiogram** would assess for **pulmonary hypertension** and other cardiac involvement, which are also complications of scleroderma. - **Pulmonary function tests (PFTs)** are important for evaluating the severity of ILD, but they do not provide the detailed anatomical information needed for initial staging that HRCT offers. *PET scan* - A **PET scan** is primarily used in oncology for staging and surveillance of malignancies, particularly given the patient's history of melanoma. - While melanoma could metastasize, the **new-onset telangiectasias and sclerodactyly**, along with a **positive ANA**, point much more strongly to a new rheumatologic condition like systemic sclerosis, for which PET is not the primary staging modality.

Q: A 28-year-old woman presents with new-onset blisters on sun-exposed areas and malar rash. Labs show ANA 1:320, anti-dsDNA positive, low C3/C4. Skin biopsy shows subepidermal blister with neutrophilic infiltrate. Most appropriate initial treatment is:

Hydroxychloroquine plus systemic steroids. ***Hydroxychloroquine plus systemic steroids*** - The patient presents with **lupus flares** characterized by a malar rash and positive **anti-dsDNA antibodies** in the presence of immune complex-mediated skin disease (blisters on sun-exposed areas) and hypocomplementemia (low C3/C4) [1]. - **Hydroxychloroquine** is a standard treatment for **cutaneous lupus** and helps prevent systemic flares, while **systemic steroids** are appropriate for managing acute, severe inflammation and blisters [1]. *Dapsone alone* - While **dapsone** can be used for blistering skin conditions, particularly **dermatitis herpetiformis** or some lupus-associated bullous lesions, it is insufficient as monotherapy given the systemic nature of her lupus with active disease (malar rash, positive anti-dsDNA, hypocomplementemia). - It does not address the underlying systemic immunological dysregulation or the extent of the skin involvement in this patient. *Hydroxychloroquine alone* - **Hydroxychloroquine** is a cornerstone of lupus treatment, particularly for cutaneous symptoms and preventing flares [1]. However, for acute, severe manifestations like extensive blistering lesions and severe malar rash, especially with systemic involvement (positive anti-dsDNA, low complement), it is often not sufficient on its own to achieve rapid control of inflammation. - Adding **systemic steroids** is crucial for prompt resolution of acute, severe symptoms and to prevent organ damage [1]. *Mycophenolate mofetil* - **Mycophenolate mofetil (MMF)** is an immunosuppressant typically reserved for more severe manifestations of lupus, such as **lupus nephritis** or other organ-threatening disease, or as a steroid-sparing agent. - While it could be considered in refractory cases, it is not the **initial treatment** of choice for an acute, severe flare dominated by cutaneous symptoms, where oral steroids provide more rapid relief.

Q: A patient with rheumatoid arthritis presents with sudden onset wrist drop. What is the most likely cause?

Tendon Rupture. ***Tendon Rupture*** - In rheumatoid arthritis, **chronic inflammation** can lead to weakening and eventual rupture of tendons, particularly the extensor tendons of the wrist, resulting in a **wrist drop**. [1] - The **sudden onset** of wrist drop is highly suggestive of a mechanical failure like a tendon rupture, as opposed to a more gradual process. *Joint Destruction* - While rheumatoid arthritis causes significant joint destruction, it typically manifests as pain, deformity, and reduced range of motion, not usually a **sudden-onset functional deficit** like wrist drop. - Joint destruction can contribute to tendon dysfunction but is not the direct, most likely cause of a **sudden wrist drop**. *Muscle Weakness* - Muscle weakness in rheumatoid arthritis often results from **disuse atrophy**, **steroid myopathy**, or **direct inflammatory effects**, but it tends to be more generalized or gradual. [1] - It would not typically cause a **sudden, focally disabling symptom** like a wrist drop in a specific part of the limb. *Nerve Compression* - **Nerve compression**, such as **carpal tunnel syndrome** (median nerve) or **ulnar nerve entrapment**, can occur in RA. - However, nerve compression leading to a wrist drop would typically involve the **radial nerve**, and while possible, **tendon rupture** is a more common and classic cause of sudden wrist drop in RA due to chronic inflammation.

Q: A 25-year-old presents with back pain, morning stiffness >1 hour, and restricted chest expansion. What is the most likely HLA association?

HLA-B27. ***HLA-B27*** - The presentation of **back pain**, morning stiffness lasting **over 1 hour**, and **restricted chest expansion** are classic symptoms of **ankylosing spondylitis**. [1] - **Ankylosing spondylitis** has a very strong association with the presence of the **HLA-B27** allele. [1] *HLA-DQ2* - **HLA-DQ2** (along with HLA-DQ8) is strongly associated with **celiac disease**, an autoimmune disorder affecting the small intestine. - Its association is not with inflammatory back pain or restricted chest expansion as seen in this patient. *HLA-B51* - **HLA-B51** is the most significant genetic risk factor for **Behçet's disease**, a chronic inflammatory disorder that causes oral and genital ulcers, as well as eye and skin lesions. - It is not typically linked to spondyloarthropathies like ankylosing spondylitis. [1] *HLA-DR4* - **HLA-DR4** is a major genetic susceptibility factor for **rheumatoid arthritis**, an autoimmune disease primarily affecting the small joints of the hands and feet. - While rheumatoid arthritis can cause morning stiffness, it rarely presents with restricted chest expansion due to spinal involvement.

Question 1

Tophi in gout found in all regions except -

Accepted Answer

Muscle

Answer

Joint capsule

Answer

Articular cartilage

Answer

Skin

Question 2

In Raynaud's disease true is :

Accepted Answer

More common in female

Answer

Sup. thrombophlebitis

Answer

Lower limb more commonly involved than upper limb

Answer

Associated with migraine

Question 3

Specific antibody for SLE is -

Accepted Answer

Anti ds DNA

Answer

Anti-La

Answer

Anti-Jo

Answer

Anti-Ro

Question 4

Which one of the following conditions is not associated with rheumatoid arthritis? (If all are associated, select 'None').

Accepted Answer

None of the options

Answer

Cricoarytenoid arthritis

Answer

Pleural effusion

Answer

Pulmonary hypertension

Question 5

A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?

Accepted Answer

Add Sulfasalazine

Answer

Continue Methotrexate and steroids at higher dose

Answer

Stop oral Methotrexate and start parenteral Methotrexate

Answer

Start treatment with anti-TNF alpha drugs

Question 6

A 35-year-old woman with history of melanoma develops new-onset facial telangiectasias and sclerodactyly. ANA is positive. Most appropriate next step for staging is:

Accepted Answer

High-resolution chest CT

Answer

Skin biopsy only

Answer

Echocardiogram with PFTs

Answer

PET scan

Question 7

A 62-year-old woman with rheumatoid arthritis presents with painful lower leg ulcers, livedo reticularis, and palpable purpura. Labs show high RF, low C3/C4, positive cryoglobulins. Most appropriate first-line treatment is:

Accepted Answer

Rituximab

Answer

Prednisone alone

Answer

Cyclophosphamide

Answer

Methotrexate

Question 8

A 28-year-old woman presents with new-onset blisters on sun-exposed areas and malar rash. Labs show ANA 1:320, anti-dsDNA positive, low C3/C4. Skin biopsy shows subepidermal blister with neutrophilic infiltrate. Most appropriate initial treatment is:

Accepted Answer

Hydroxychloroquine plus systemic steroids

Answer

Dapsone alone

Answer

Hydroxychloroquine alone

Answer

Mycophenolate mofetil

Question 9

A patient with rheumatoid arthritis presents with sudden onset wrist drop. What is the most likely cause?

Accepted Answer

Tendon Rupture

Answer

Joint Destruction

Answer

Muscle Weakness

Answer

Nerve Compression

Question 10

A 25-year-old presents with back pain, morning stiffness >1 hour, and restricted chest expansion. What is the most likely HLA association?

Accepted Answer

HLA-B27

Answer

HLA-DQ2

Answer

HLA-B51

Answer

HLA-DR4

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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