Rheumatology and Immunology Practice Questions

Q: The most likely diagnosis in the case of a patient with multiple pulmonary cavities, hematuria, and red cell casts is?

Wegener's granulomatosis. ***Wegener's granulomatosis (Granulomatosis with Polyangiitis)*** - This condition classically presents with a **triad of upper airway, lower airway, and renal involvement** [1]. **Pulmonary cavities** represent severe lung involvement, and **hematuria with red cell casts** indicate rapidly progressive glomerulonephritis [3]. - It is an **ANCA-associated vasculitis**, specifically associated with **c-ANCA (anti-PR3 antibodies)**, and often leads to **granulomatous inflammation** [1], [3]. *Anti-GBM disease* - Characterized by **glomerulonephritis** and **pulmonary hemorrhage** (Goodpasture's syndrome) [1], but does not typically cause multiple **pulmonary cavities**. - Diagnosed by the presence of **anti-glomerular basement membrane antibodies** and linear IgG deposition on renal biopsy [1]. *Churg-Strauss* - This condition, now known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, is characterized by **asthma, eosinophilia, and vasculitis** [1]. - While it can affect the lungs and kidneys, **pulmonary cavities** are less common, and severe eosinophilia is a hallmark, which is not mentioned here [1]. *Systemic lupus erythematosus* - A multisystem autoimmune disease that can cause **glomerulonephritis (lupus nephritis)** and pleuropulmonary involvement [2]. - However, **multiple pulmonary cavities** are not a typical manifestation, and other classic lupus features (e.g., malar rash, arthralgias) are absent in the description [2].

Q: Arthritis involving DIP, PIP, 1st carpometacarpal with sparing of MCP and wrist joints is typical of ?

Osteoarthritis. ***Osteoarthritis*** - **Osteoarthritis** characteristically affects the **DIP (Heberden's nodes)**, **PIP (Bouchard's nodes)**, and the **first carpometacarpal joint** at the base of the thumb [1]. - It typically spares the **MCP and wrist joints**, which helps differentiate it from inflammatory arthropathies like rheumatoid arthritis [1], [2]. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **MCP and wrist joints**, sparing the DIP joints [2]. - It presents with **symmetrical polyarthritis** and often includes systemic symptoms [2]. *Ankylosing spondylitis* - **Ankylosing spondylitis** primarily affects the **axial skeleton**, particularly the sacroiliac joints and spine. - While peripheral joint involvement can occur, it's typically in larger joints and not the characteristic DIP/PIP pattern of this case. *Psoriatic arthritis* - **Psoriatic arthritis** can affect the **DIP joints** and can present with patterns similar to osteoarthritis or rheumatoid arthritis [3]. - However, it's strongly associated with **psoriasis** (skin and nail changes) and can involve various other patterns, including **dactylitis** (sausage digits) and enthesitis, which makes it less typical for the described sparing pattern alone [3].

Q: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?

Lupus nephritis. ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.

Q: A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

Osteoarthritis. ***Osteoarthritis*** - **Osteoarthritis** typically affects the **1st carpometacarpal (CMC)* joint (of which the 1st MCP is a part), **proximal interphalangeal (PIP)**, and **distal interphalangeal (DIP)** joints, consistent with the patient's presentation [1]. - It classically **spares the wrist and ankle joints** in its early stages, supporting this diagnosis. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints symmetrically, but typically **spares the distal interphalangeal (DIP) joints** [1]. - It frequently involves the **wrist and ankle joints**, which are noted as spared in this case [1]. *Psoriatic arthritis* - **Psoriatic arthritis** can affect DIP joints and may present with different patterns, but a classic presentation often includes **dactylitis** (sausage digits) or nail changes, which are not mentioned [1]. - While it can affect the hand joints, the specific pattern described, including the sparing of the wrist and ankle, is not its most typical presentation. *Gout* - **Gout** is characterized by acute, severe pain, typically in a single joint, with the **first metatarsophalangeal (MTP) joint** (of the big toe) being most commonly affected, known as podagra. - While gout can affect other joints, its episodic nature and acute inflammatory presentation differ from the chronic, progressive pattern suggested by the question.

Q: Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

ANCA is typically negative in PAN.. ***30% of people have HbsAg positive*** - Hepatitis B virus infection is associated with **polyarteritis nodosa (PAN)**, with **30%** of patients having a positive **HbsAg**. - The presence of **HbsAg** indicates active Hepatitis B, which can lead to vasculitis seen in PAN. *Microscopy shows fibrinoid necrosis in large arteries* - While fibrinoid necrosis is present in vasculitides [1], it is more characteristic of **granulomatosis with polyangiitis** (Wegener's) rather than PAN. - PAN typically shows **intranuclear inclusions** and necrotizing vasculitis without predominant fibrinoid necrosis. *Patient have hypogammaglobulinemia* - Patients with PAN do not typically present with **hypogammaglobulinemia**; rather, they may have normal immunoglobulin levels. - Hypogammaglobulinemia is more commonly associated with other types of vasculitis, such as **SLE** or **chronic infections**. *ANCA is positive* - Perinuclear anti-neutrophil cytoplasmic antibodies (**ANCA**) are usually associated with **granulomatosis and eosinophilic granulomatosis** rather than PAN. - PAN is **ANCA-negative** and is characterized by alternate antibodies, particularly if associated with Hepatitis B.

Q: Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

Presence of rheumatoid factor (RF). Presence of rheumatoid factor (RF) - **Seropositive rheumatoid arthritis** is specifically defined by the presence of **rheumatoid factor (RF)** or anti-citrullinated protein antibodies (anti-CCP), indicating a particular immunological subtype of the disease [1]. - The detection of **RF**, an autoantibody, is a key diagnostic marker that helps differentiate seropositive RA from seronegative forms and other inflammatory arthritides [1]. Joint deformities - Joint deformities, such as **ulnar deviation** or **boutonnière and swan neck deformities**, are a common *consequence* of chronic, uncontrolled rheumatoid arthritis [2]. - While characteristic of advanced disease, deformities are not a *defining feature* for the initial classification of **seropositive RA**, which is based on serological markers. Morning stiffness lasting more than 30 minutes - **Morning stiffness** that persists for more than 30 minutes is a classic *symptom* of inflammatory arthritis, including both seropositive and seronegative RA [3]. - Although it is an important diagnostic criterion for RA in general, it is not specific to the **seropositive subtype** because it can be present in other inflammatory arthropathies as well [3]. Generalized joint pain and swelling - **Generalized joint pain and swelling**, typically in a symmetrical pattern affecting small joints, are core *symptoms* of rheumatoid arthritis and indicate active inflammation [3]. - These symptoms are common in all forms of RA, including both seropositive and seronegative, and thus do not specifically characterize the **seropositive subtype**.

Q: Sausage finger appearance is associated with which of the following conditions?

Psoriatic arthritis. ***Psoriatic arthritis*** - **Dactylitis**, or "sausage finger," is a characteristic inflammatory finding in psoriatic arthritis, resulting from inflammation of the **entire digit** [1]. - This condition involves inflammation of tendons, joints, and soft tissues which leads to diffuse swelling of fingers or toes [1]. *Rickets* - Rickets is a bone-softening disease in children caused by **vitamin D deficiency**, leading to bone deformities like bowed legs or widened wrists. - It does not present with inflammatory dactylitis or "sausage digits." *Hyperthyroidism* - Hyperthyroidism is a condition of excessive thyroid hormone production, which can cause symptoms like **tremors**, **tachycardia**, and **weight loss** [2]. - It is not associated with dactylitis or changes in finger morphology. *Addison's disease* - Addison's disease results from **adrenal insufficiency**, leading to symptoms like **fatigue**, **skin hyperpigmentation**, and hypotension. - There is no clinical association between Addison's disease and "sausage finger" appearance.

Q: Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

ANCA. ### ANCA - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points towards a small-vessel vasculitis, for which **ANCA (anti-neutrophil cytoplasmic antibodies)** testing is crucial [1]. - ANCA is highly specific for conditions like **Granulomatosis with Polyangiitis (GPA)** and **Microscopic Polyangiitis (MPA)** [1]. ### RA factor - **Rheumatoid factor (RF)** is primarily associated with **rheumatoid arthritis**, which typically presents with symmetrical polyarthritis, not the constellation of symptoms described. - While RF can be positive in some vasculitides, it is not the most specific initial test for the given clinical presentation. ### Hbsag - **Hepatitis B surface antigen (HbsAg)** typically screens for **Hepatitis B infection**, which can cause **polyarteritis nodosa (PAN)**, a medium-vessel vasculitis. - However, the patient's symptoms (cutaneous vasculitis, glomerulonephritis) are more characteristic of **small-vessel vasculitis**, making ANCA a more direct investigation [1]. ### MIF - **MIF (Macrophage Migration Inhibitory Factor)** is a cytokine involved in inflammation, but it is not a routine diagnostic marker for vasculitis. - It is not used as a primary investigation to diagnose specific autoimmune or inflammatory conditions like vasculitis.

Q: A 23-year old woman has experienced episodes of myalgias, pleural effusion, pericarditis and arthralgias without joint deformity over course of several years. The best laboratory screening test to diagnose her disease would be -

Antinuclear antibody. ***Antinuclear antibody*** - The constellation of **myalgias**, **pleural effusion**, **pericarditis**, and **arthralgias without joint deformity** is highly suggestive of **systemic lupus erythematosus (SLE)**. - **Antinuclear antibodies (ANA)** are present in over 95% of patients with SLE and are the primary screening test for this condition [1]. *CD4/CD8 lymphocyte count* - This count is more relevant for monitoring **immunodeficiency** conditions like **HIV infection**, where it helps assess immune status. - While lymphocytes can be affected in autoimmune diseases, a CD4/CD8 count is not a primary screening test for SLE. *Erythrocyte sedimentation rate* - An **elevated ESR** indicates general inflammation and is a **non-specific marker** [2]. - While it is often elevated in SLE, it doesn't confirm the diagnosis and can be high in numerous other inflammatory conditions [1]. *Assay for thyroid hormones* - An assay for thyroid hormones is used to diagnose **thyroid disorders** like **hypothyroidism** or **hyperthyroidism**. - There is no direct link between thyroid hormone levels and the symptoms described in the patient.

Q: In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?

Gout. ***Gout*** - **Gout** is characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints, most often the **big toe** [1],[2]. - A history of **high uric acid levels** (hyperuricemia) is a primary risk factor, as it leads to the formation of **uric acid crystals** in the joint [1],[3]. *Ankylosing spondylitis* - This condition is a chronic inflammatory disease primarily affecting the **spine and sacroiliac joints**, causing stiffness and pain, especially in the morning. - It is not directly associated with **high uric acid levels** or generally presenting as an acute, single swollen joint attack. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease characterized by the breakdown of cartilage over time, leading to pain and stiffness, especially with activity. - While it can cause joint swelling, it is typically a gradual process, not an acute, intensely painful attack, and is not linked to **uric acid levels**. *Rheumatoid arthritis* - **Rheumatoid arthritis** is an autoimmune disease causing chronic inflammation, primarily affecting multiple small joints symmetrically. - It presents with prolonged morning stiffness and is not directly caused by **high uric acid levels**, nor is its typical presentation an acute monoarthritis.

Question 1

The most likely diagnosis in the case of a patient with multiple pulmonary cavities, hematuria, and red cell casts is?

Accepted Answer

Wegener's granulomatosis

Answer

Anti-GBM disease

Answer

Churg-Strauss

Answer

Systemic lupus erythematousus

Question 2

Arthritis involving DIP, PIP, 1st carpometacarpal with sparing of MCP and wrist joints is typical of ?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Question 3

A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and    new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely    diagnosis?

Accepted Answer

Lupus nephritis

Answer

Acute interstitial nephritis

Answer

Poststreptococcal glomerulonephritis

Answer

IgA nephropathy

Question 4

A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Gout

Question 5

Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

Accepted Answer

ANCA is typically negative in PAN.

Answer

Patients with PAN may exhibit hypergammaglobulinemia.

Answer

Approximately 30% of patients with Polyarteritis Nodosa (PAN) are HBsAg positive.

Answer

Microscopy shows fibrinoid necrosis in medium-sized arteries

Question 6

Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

Accepted Answer

Presence of rheumatoid factor (RF)

Answer

Generalized joint pain and swelling

Answer

Morning stiffness lasting more than 30 minutes

Answer

Joint deformities

Question 7

Sausage finger appearance is associated with which of the following conditions?

Accepted Answer

Psoriatic arthritis

Answer

Rickets

Answer

Hyperthyroidism

Answer

Addison's disease

Question 8

Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

Accepted Answer

ANCA

Answer

RA factor

Answer

Hbsag

Answer

MIF

Question 9

A 23-year old woman has experienced episodes of myalgias, pleural effusion, pericarditis and arthralgias without joint deformity over course of several years. The best laboratory screening test to diagnose her disease would be -

Accepted Answer

Antinuclear antibody

Answer

Erythrocyte sedimentation rate

Answer

Assay for thyroid hormones

Answer

CD4/CD8 lymphocyte count

Question 10

In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?

Accepted Answer

Gout

Answer

Ankylosing spondylitis

Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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