Rheumatology and Immunology Practice Questions

Q: A 55-year-old female with rheumatoid arthritis presents with increasing joint pain and morning stiffness despite methotrexate therapy. What is the next step in management?

Switch to a biologic agent. ***Switch to a biologic agent*** - For patients with **rheumatoid arthritis** who have inadequate response to **methotrexate** monotherapy, the next step is often to escalate treatment to a **biologic disease-modifying antirheumatic drug (DMARD)** [1]. - Biologics target specific components of the immune system involved in inflammation, offering more potent control of disease activity and structural damage progression. *Increase methotrexate dose* - While dose escalation of **methotrexate** is an option, it is typically considered before labeling a patient as a "non-responder" if they are on a suboptimal dose [1]. - However, for patients already on an adequate dose and still experiencing uncontrolled symptoms, further increasing the dose may not be effective and could increase side effects [1]. *Add hydroxychloroquine* - **Hydroxychloroquine** is a **DMARD** but generally less potent than **methotrexate** or biologics, making it less suitable as the next step for a patient with persistent symptoms despite methotrexate. - It is often used in milder cases or in combination with other **DMARDs**, but usually not as the primary augmentation for refractory disease. *Start prednisone* - **Prednisone** is a corticosteroid that can provide rapid symptom relief due to its anti-inflammatory effects [1]. - However, it is primarily used for **short-term relief** during flares or as a bridge to other **DMARDs** due to significant long-term side effects and does not modify the underlying disease process [1].

Q: A 35-year-old female presents with pain and stiffness in her fingers that worsens in the morning and improves with activity. Which autoimmune disorder should be suspected?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Morning stiffness** lasting more than 30 minutes, particularly in the **small joints** of the hands and feet, is a hallmark feature of rheumatoid arthritis [1]. - The improvement of symptoms with activity is also characteristic [1], contrasting with conditions like osteoarthritis, which often worsens with activity [2]. *Systemic lupus erythematosus* - SLE can cause joint pain, but it typically does not present with prolonged morning stiffness that improves with activity in the same specific pattern as rheumatoid arthritis. - SLE is also associated with a wider range of systemic symptoms, such as **malar rash**, photosensitivity, and renal involvement, none of which are mentioned here. *Gout* - Gout typically presents as **acute, severe joint pain**, often affecting a single joint (most commonly the **first metatarsophalangeal joint**), rather than widespread morning stiffness. - The pain in gout is characteristically sudden and intense, not gradually improving with activity. *Osteoarthritis* - Osteoarthritis a **degenerative joint disease** whose pain usually **worsens with activity** and improves with rest [2]. - While osteoarthritis can cause morning stiffness, it is typically of shorter duration (less than 30 minutes) and localized to the affected joints, often larger weight-bearing joints, though it can affect the hands [2].

Q: A 45-year-old female presents with dry eyes, dry mouth, and joint pain. Which of the following antibodies is most indicative of the suspected condition?

Anti-Ro/SSA antibodies. ***Anti-Ro/SSA antibodies*** - The patient's symptoms of **dry eyes (xerophthalmia)**, **dry mouth (xerostomia)**, and **joint pain** are classic manifestations of **Sjögren's syndrome**, a chronic autoimmune disease. [1] - **Anti-Ro/SSA antibodies** are highly specific for Sjögren's syndrome, particularly in patients with primary Sjögren's. [1] *Anti-histone antibodies* - These antibodies are most commonly associated with **drug-induced lupus erythematosus**, a condition characterized by lupus-like symptoms that develop after exposure to certain medications. - The clinical presentation of dry eyes and dry mouth is not the primary distinguishing feature of drug-induced lupus. *Anti-thyroid peroxidase antibodies* - These antibodies are a hallmark of **Hashimoto's thyroiditis**, an autoimmune disease affecting the thyroid gland and leading to hypothyroidism. [2] - While Sjögren's syndrome can coexist with other autoimmune conditions, anti-thyroid peroxidase antibodies do not directly indicate Sjögren's. *Anti-phospholipid antibodies* - These antibodies are primarily associated with **antiphospholipid syndrome**, a thrombophilic disorder characterized by arterial or venous thrombosis and/or adverse pregnancy outcomes. - They are not directly indicative of the sicca symptoms seen in Sjögren's syndrome.

Q: A 70-year-old male with rheumatoid arthritis presents with progressive joint pain, swelling, and subcutaneous nodules. Which laboratory investigations are most appropriate to confirm a flare-up of rheumatoid arthritis compared to conditions like gout or septic arthritis?

Joint aspiration, ESR, and uric acid. ***Joint aspiration, ESR, and uric acid*** - **Joint aspiration** allows for microscopic examination of synovial fluid, which can reveal inflammatory cells characteristic of RA, and exclude crystals (gout) or bacteria (septic arthritis). - **ESR (Erythrocyte Sedimentation Rate)** is a non-specific marker of inflammation that would be elevated in an RA flare-up, while **uric acid** levels help rule out gout as a differential [1]. *Rheumatoid factor, ANA, and synovial fluid culture* - **Rheumatoid Factor (RF)** is typically already known to be positive in a patient with an established diagnosis of RA and does not specifically indicate a flare [1]. - **ANA (Antinuclear Antibodies)** are more associated with lupus and other autoimmune diseases, and while sometimes positive in RA, are not primary markers for flare-ups. *Anti-CCP antibodies, CRP, and synovial fluid culture* - **Anti-CCP antibodies** are highly specific for RA and are useful for initial diagnosis [1]. - While **CRP (C-reactive protein)** is a good marker of inflammation and would be elevated in a flare, **synovial fluid culture** primarily rules out septic arthritis rather than confirming an RA flare. *X-rays of the hands, anti-dsDNA antibodies, and serum complement levels* - **X-rays of the hands** are useful for assessing joint damage and progression over time in RA but do not provide immediate information about an acute flare-up. - **Anti-dsDNA antibodies** and **serum complement levels** are primarily associated with systemic lupus erythematosus (SLE) and are not standard investigations for an RA flare or to differentiate it from gout or septic arthritis.

Q: A 45-year-old woman with rheumatoid arthritis on maximum methotrexate and low-dose prednisone for 6 months has 8 swollen and 10 tender joints, with an ESR of 40 and CRP of 3. What is the next step according to the ACR guidelines?

Switch to a TNF inhibitor. ***Switch to a TNF inhibitor*** - This patient has **active rheumatoid arthritis** despite being on **maximum methotrexate** and low-dose prednisone, indicated by high swollen and tender joint counts, and elevated inflammatory markers (ESR, CRP) [1]. - According to ACR guidelines, if a patient fails to achieve **low disease activity** or remission after 3-6 months on initial DMARD therapy (like methotrexate), the next step is to add or switch to a **biologic agent**, such as a **TNF inhibitor** [1]. *Increase the dose of MTX* - The patient is already on **maximum methotrexate** (implied by "maximum methotrexate" in the stem), so increasing the dose further would likely not be beneficial and could increase toxicity [2]. - ACR guidelines suggest moving to a new class of therapy rather than simply escalating a maximum-dose DMARD that has failed [1]. *Refer the patient to physical therapy* - While **physical therapy** is an important adjunctive treatment for rheumatoid arthritis to maintain joint function and reduce pain, it is not the primary next step when there is **uncontrolled disease activity** on maximum medical therapy. - The immediate priority is to control the underlying inflammation. *Add hydroxychloroquine (HCQ) to the regimen* - **Hydroxychloroquine** is a good option for mild RA or as part of a combination DMARD therapy, but it is generally less potent than methotrexate or biologic agents. - Adding HCQ alone is unlikely to be sufficient to control the severe, active disease seen in this patient who has failed maximum methotrexate [1].

Q: A 30-year-old woman presents with recurrent miscarriages, livedo reticularis, and a positive lupus anticoagulant test. What is the most likely diagnosis?

Antiphospholipid syndrome. ***Antiphospholipid syndrome*** - The classic triad of **recurrent miscarriages**, **livedo reticularis**, and a **positive lupus anticoagulant test** is diagnostic for antiphospholipid syndrome. - This syndrome is characterized by **thrombotic events** (arterial or venous) and/or **pregnancy morbidity** in the presence of antiphospholipid antibodies. *Systemic lupus erythematosus* - While antiphospholipid syndrome can occur as a secondary condition to **systemic lupus erythematosus (SLE)**, the patient's presentation primarily points to APS itself [1]. - SLE typically involves a broader range of symptoms including **arthritis**, **malar rash**, **renal disease**, and **serositis**, which are not mentioned here [2]. *Rheumatoid arthritis* - **Rheumatoid arthritis** is an autoimmune disease primarily affecting the **joints**, causing pain, swelling, and stiffness [2]. - It does not typically cause **recurrent miscarriages**, **livedo reticularis**, or a **positive lupus anticoagulant test**. *Thrombophilia* - **Thrombophilia** is a general term for a condition that increases the risk of **thrombosis**. - While APS is a type of acquired thrombophilia, simply stating "thrombophilia" is too broad and does not pinpoint the specific syndrome identified by the constellation of symptoms and test results.

Q: A 55-year-old female presents with pain in her hips and knees, along with joint stiffness in the morning. Examination reveals Heberden's nodes. What is the most likely diagnosis?

Osteoarthritis. ***Osteoarthritis*** - **Heberden's nodes** (affecting the distal interphalangeal joints) are a classic sign of osteoarthritis, especially in women [1]. - The presentation of **hip and knee pain** with morning stiffness, indicative of **degenerative joint disease**, further supports this diagnosis [1]. *Rheumatoid arthritis* - Typically affects the **small joints** of the hands and feet symmetrically [2], and can cause **Bouchard's nodes** (proximal interphalangeal joints) but not Heberden's [1]. - Morning stiffness in rheumatoid arthritis is usually **prolonged (over 30 minutes to an hour)** and improves with activity. *Gout* - Characterized by **sudden, severe attacks** of pain, redness, and swelling, often affecting a single joint, most commonly the **big toe**. - Does not typically present with Heberden's nodes or widespread chronic hip and knee pain. *Psoriatic arthritis* - Associated with **psoriasis** and often presents with **dactylitis** (sausage digits) and nail changes, none of which are mentioned here. - Involves both axial and peripheral joints but **Heberden's nodes are not a characteristic finding** [2].

Q: A 50-year-old woman presents with dry mouth, dry eyes, and bilateral parotid gland swelling. Schirmer's test is positive. Which antibodies are most likely to be positive in this patient?

Anti-Ro/SSA and anti-La/SSB. ### Anti-Ro/SSA and anti-La/SSB - The constellation of **dry mouth (xerostomia)**, **dry eyes (xerophthalmia)**, and **bilateral parotid gland swelling**, along with a **positive Schirmer's test**, is highly indicative of **Sjögren's syndrome**. - **Anti-Ro/SSA** and **anti-La/SSB** antibodies are the most specific serological markers for Sjögren's syndrome, particularly in primary cases [1]. *Anti-dsDNA and anti-Smith* - These antibodies are highly specific for **Systemic Lupus Erythematosus (SLE)**, a condition with diverse systemic manifestations, not primarily dry glands [1]. - While Sjögren's can sometimes co-exist with SLE, the primary presentation described points directly to Sjögren's syndrome as the main diagnosis, where these antibodies are not typically the most indicative [1]. *Anti-centromere and anti-Scl-70* - **Anti-centromere antibodies** are associated with **limited cutaneous systemic sclerosis (CREST syndrome)**, which involves features like calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias. - **Anti-Scl-70 (topoisomerase I)** antibodies are specific for **diffuse cutaneous systemic sclerosis**, characterized by widespread skin thickening and internal organ involvement. Neither of these conditions presents primarily with dry glands and parotid swelling. *Anti-CCP and RF* - **Anti-CCP (cyclic citrullinated peptide)** antibodies and **rheumatoid factor (RF)** are the primary serological markers for **Rheumatoid Arthritis (RA)**. - RA typically presents with chronic **symmetric polyarthritis**, particularly of small joints, and does not commonly manifest with prominent dry eyes, dry mouth, or parotid swelling as the initial or defining features.

Q: A 60-year-old patient presents with severe headache, visual disturbances, and elevated ESR. A biopsy shows granulomatous inflammation of the temporal artery. What is the immediate management?

High-dose corticosteroids. ***High-dose corticosteroids*** - Immediate initiation of **high-dose corticosteroids** is critical to prevent **permanent vision loss** in conditions like giant cell arteritis [1]. - The strong **anti-inflammatory effects** of corticosteroids help manage **symptoms** and address the underlying granulomatous inflammation [1]. *Surgical resection* - Surgical intervention does not address the **inflammatory process** and is not indicated in acute management of giant cell arteritis. - This method may be considered if there are complications, but it is **not a first-line treatment**. *Methotrexate* - Methotrexate is not the first choice in **giant cell arteritis** [1]; it is typically used in chronic inflammatory conditions and rheumatoid arthritis. - The immediate requirement is high-dose glucocorticoids to relieve inflammation, rather than **slow-acting immunosuppressants**. *Low-dose aspirin* - While **low-dose aspirin** can be beneficial for **cardiovascular protection**, it does not directly address the **inflammatory symptoms** in giant cell arteritis. - Aspirin may help reduce transient ischemic attacks but is not a substitute for the necessary **high-dose corticosteroids**.

Q: A 29-year-old man presents with recurrent oral ulcers, uveitis, and arthritis. Which HLA subtype is most commonly associated with his condition?

HLA-B51. ***HLA-B51*** - The constellation of **recurrent oral ulcers**, **uveitis**, and **arthritis** in a young man is highly suggestive of **Behçet's disease**. - **HLA-B51** is the most strongly associated genetic marker with Behçet's disease, particularly in patients of Middle Eastern, Mediterranean, and East Asian descent. *HLA-B27* - **HLA-B27** is primarily associated with **seronegative spondyloarthropathies**, such as **ankylosing spondylitis** and **reactive arthritis** [1]. - While uveitis can occur in these conditions, recurrent oral ulcers are not a prominent feature, and the overall clinical picture doesn't fit Behçet's disease [1]. *HLA-DR4* - **HLA-DR4** is most strongly linked to **rheumatoid arthritis**, a chronic inflammatory condition primarily affecting joints. - Ocular involvement in rheumatoid arthritis typically manifests as **scleritis** or **episcleritis**, and recurrent oral ulcers are not a characteristic symptom. *HLA-DR3* - **HLA-DR3** is associated with several autoimmune diseases, including **systemic lupus erythematosus (SLE)**, **Sjögren's syndrome**, and **Type 1 diabetes** [2]. - While SLE can cause oral ulcers and arthritis, uveitis is less common, and Sjögren's primarily causes sicca symptoms.

Question 1

A 55-year-old female with rheumatoid arthritis presents with increasing joint pain and morning stiffness despite methotrexate therapy. What is the next step in management?

Accepted Answer

Switch to a biologic agent

Answer

Increase methotrexate dose

Answer

Add hydroxychloroquine

Answer

Start prednisone

Question 2

A 35-year-old female presents with pain and stiffness in her fingers that worsens in the morning and improves with activity. Which autoimmune disorder should be suspected?

Accepted Answer

Rheumatoid arthritis

Answer

Systemic lupus erythematosus

Answer

Gout

Answer

Osteoarthritis

Question 3

A 45-year-old female presents with dry eyes, dry mouth, and joint pain. Which of the following antibodies is most indicative of the suspected condition?

Accepted Answer

Anti-Ro/SSA antibodies

Answer

Anti-histone antibodies

Answer

Anti-thyroid peroxidase antibodies

Answer

Anti-phospholipid antibodies

Question 4

A 70-year-old male with rheumatoid arthritis presents with progressive joint pain, swelling, and subcutaneous nodules. Which laboratory investigations are most appropriate to confirm a flare-up of rheumatoid arthritis compared to conditions like gout or septic arthritis?

Accepted Answer

Joint aspiration, ESR, and uric acid

Answer

Anti-CCP antibodies, CRP, and synovial fluid culture

Answer

Rheumatoid factor, ANA, and synovial fluid culture

Answer

X-rays of the hands, anti-dsDNA antibodies, and serum complement levels

Question 5

A 45-year-old woman with rheumatoid arthritis on maximum methotrexate and low-dose prednisone for 6 months has 8 swollen and 10 tender joints, with an ESR of 40 and CRP of 3. What is the next step according to the ACR guidelines?

Accepted Answer

Switch to a TNF inhibitor

Answer

Increase the dose of MTX

Answer

Refer the patient to physical therapy

Answer

Add hydroxychloroquine (HCQ) to the regimen

Question 6

A 30-year-old woman presents with recurrent miscarriages, livedo reticularis, and a positive lupus anticoagulant test. What is the most likely diagnosis?

Accepted Answer

Antiphospholipid syndrome

Answer

Systemic lupus erythematosus

Answer

Rheumatoid arthritis

Answer

Thrombophilia

Question 7

A 55-year-old female presents with pain in her hips and knees, along with joint stiffness in the morning. Examination reveals Heberden's nodes. What is the most likely diagnosis?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Gout

Answer

Psoriatic arthritis

Question 8

A 50-year-old woman presents with dry mouth, dry eyes, and bilateral parotid gland swelling. Schirmer's test is positive. Which antibodies are most likely to be positive in this patient?

Accepted Answer

Anti-Ro/SSA and anti-La/SSB

Answer

Anti-dsDNA and anti-Smith

Answer

Anti-centromere and anti-Scl-70

Answer

Anti-CCP and RF

Question 9

A 60-year-old patient presents with severe headache, visual disturbances, and elevated ESR. A biopsy shows granulomatous inflammation of the temporal artery. What is the immediate management?

Accepted Answer

High-dose corticosteroids

Answer

Methotrexate

Answer

Low-dose aspirin

Answer

Surgical resection

Question 10

A 29-year-old man presents with recurrent oral ulcers, uveitis, and arthritis. Which HLA subtype is most commonly associated with his condition?

Accepted Answer

HLA-B51

Answer

HLA-B27

Answer

HLA-DR4

Answer

HLA-DR3

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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