Rheumatology and Immunology Practice Questions

Q: Which is the rheumatoid arthritis autoantibody?

Anti CCP. ***Anti CCP*** - **Anti-Citrullinated Protein Antibodies (CCP)** are highly specific for **rheumatoid arthritis** and are used for diagnosing this condition. - A positive **Anti-CCP** test can indicate the presence of **rheumatoid arthritis** even before clinical symptoms appear. *Anti histone* - This antibody is primarily associated with **drug-induced lupus erythematosus**, not rheumatoid arthritis. - It identifies a **response** to medications, rather than being a specific marker for a rheumatic condition like RA. *Anti DLE* - Suggests antibodies related to **discoid lupus erythematosus**, not rheumatoid arthritis. - These antibodies do not correlate with inflammatory joint disease or diagnosis of RA. *Anti ds DNA* - Commonly associated with **systemic lupus erythematosus** (SLE) rather than rheumatoid arthritis [1]. - While relevant for lupus, it lacks specificity for diagnosing rheumatic arthritis; ANA testing is noted as not useful in diagnosing RA specifically [1].

Q: Which of the following conditions is least likely to present with polyarticular involvement in clinical practice?

Gout. ***Gout*** - Classically presents as **monoarticular arthritis**, affecting a single joint (typically the **first metatarsophalangeal joint** in 85-90% of acute attacks). - While chronic **tophaceous gout** can involve multiple joints, acute presentations are predominantly **monoarticular**, making it the least likely to present with polyarticular involvement. *Psoriatic arthritis* - Often presents with **symmetric polyarthritis** pattern similar to rheumatoid arthritis, involving multiple small and large joints. - Can also manifest as **oligoarthritis** or **spondyloarthritis**, but polyarticular involvement is common in established disease. *SLE* - Presents with **polyarthritis** in approximately **90% of patients**, typically affecting small joints of hands, wrists, and knees symmetrically. - Joint involvement is one of the most common manifestations and is included in **SLE classification criteria** due to its frequent occurrence. *Ankylosing spondylitis* - Primarily affects the **axial skeleton** (spine and sacroiliac joints) in a polyarticular pattern, causing progressive spinal fusion. - Can also involve **peripheral joints** (hips, shoulders, knees) in addition to spinal involvement, representing polyarticular disease.

Q: Most common pulmonary manifestation of SLE is which of the following?

Pleuritis. ***Pleuritis*** - **Pleuritis** and **pleural effusions** are the most common pulmonary manifestations in patients with SLE, affecting up to 50% of patients [1]. - They often present with **pleuritic chest pain** and can be diagnosed via chest X-ray or CT scan [1]. *Shrinking Lung* - **Shrinking lung syndrome** is a rare but severe manifestation characterized by decreased lung volumes and an elevated diaphragm, but it is not the most common [1]. - Its pathogenesis is unclear, but it may involve phrenic neuropathy, diaphragmatic myopathy, or chronic pleuritis with fibrosis [1]. *Intra alveolar hemorrhage* - **Diffuse alveolar hemorrhage** is a life-threatening complication of SLE, leading to acute respiratory failure and hemoptysis, but it is uncommon [1]. - It often requires aggressive immunosuppressive therapy due to its high mortality rate [1]. *Interstitial inflammation* - **Interstitial lung disease** (ILD) in SLE, manifesting as interstitial inflammation or fibrosis, is a less common pulmonary complication compared to pleuritis [1]. - While it can lead to progressive dyspnea and cough, it usually develops in a chronic course [1].

Q: Bilateral hilar lymphadenopathy, along with non-caseating granulomas, is a characteristic feature of:

Sarcoidosis. ***Sarcoidosis*** - This autoimmune disease is characterized by the formation of **non-caseating granulomas** in various organs, most commonly the lungs and lymphatic system. - **Bilateral hilar lymphadenopathy** is a classic radiographic finding, seen in up to 90% of cases, often accompanied by interstitial lung disease [1]. *Scleroderma* - Characterized by **fibrosis** of the skin and internal organs, leading to hardening and thickening of tissues. - Does not typically present with bilateral hilar lymphadenopathy or non-caseating granulomas. *SLE* - An autoimmune disease characterized by a wide array of symptoms affecting multiple organ systems, including arthritis, skin rashes, and kidney problems. - While it can manifest with lung involvement, such as pleuritis or interstitial lung disease, it does not typically involve **non-caseating granulomas** or classic hilar lymphadenopathy. *Stein-Leventhal syndrome* - Also known as **polycystic ovary syndrome (PCOS)**, it is an endocrine disorder characterized by hormonal imbalances, irregular periods, and androgen excess. - This syndrome is entirely unrelated to bilateral hilar lymphadenopathy or the formation of granulomas.

Q: A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure when she is outdoors. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)?

Antibodies to double-stranded DNA. A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure [1]. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)? ***Antibodies to double-stranded DNA*** - In **systemic lupus erythematosus (SLE)** [2], which fits the description, the presence of **anti-double-stranded DNA antibodies** is a hallmark finding. - This antibody is associated with **renal involvement** and correlates with disease activity, making it a critical laboratory finding [2]. *Elevated anti-streptolysin 0 (ASO) titer* - This test indicates recent **streptococcal infection**, not related to the symptoms or autoimmune features of SLE. - It is mainly used in the context of **rheumatic fever** and **post-streptococcal glomerulonephritis**. *Markedly decreased serum level of immunoglobulin G (IgG)* - Decreased IgG levels do not specifically indicate **SLE**, which often shows **increased overall immunoglobulin levels** due to chronic inflammation. - Hypogammaglobulinemia can occur in various conditions but is not characteristic of lupus. *HLA-B27 genotype* - This genotype is primarily associated with **spondyloarthropathies** (e.g., ankylosing spondylitis), not systemic lupus erythematosus [2]. - It is not relevant to the **cutaneous symptoms** or the autoimmune nature of the presented disease.

Q: In ankylosing spondylitis, joint involvement is least in?

Wrist and hand. Detailed explanation of joint involvement in ankylosing spondylitis: ***Wrist and hand*** - **Ankylosing spondylitis (AS)** primarily affects the **axial skeleton** (spine, sacroiliac joints) and **large peripheral joints** like the hips and shoulders. - Involvement of the small joints of the **wrist and hand** is uncommon [1] and usually occurs late in the disease course, making it the least involved area among the options. *Sacroiliac joint* - The **sacroiliac joints** are almost universally affected in AS, often being the **first joints** to show inflammation [2]. - Inflammatory changes and eventual **fusion** of these joints are hallmarks of the disease [2]. *Costochondral junction* - Involvement of the **costochondral junctions** can lead to **chest wall pain** and stiffness, contributing to the typical "bamboo spine" appearance and reduced chest expansion in AS [2]. - This is a common extra-axial manifestation of the disease, contributing to respiratory compromise. *Acromio-clavicular joint* - The **acromio-clavicular joints** can be affected in AS, causing pain and restricted movement in the shoulder girdle [1]. - This is considered a common site of **peripheral enthesitis** and articular involvement in AS [1].

Q: All of the following are true about Drug-Induced Lupus in comparison to Idiopathic SLE, except:

More common in females. ***More common in females*** - This statement is **false** for drug-induced lupus (DIL). While **idiopathic SLE** has a significant female predominance, DIL shows a **more even gender distribution** or a slightly higher incidence in males depending on the drug [1]. - Thus, DIL being *more common in females* compared to idiopathic SLE is incorrect; it is actually less pronounced. *Milder disease* - Drug-induced lupus (DIL) is generally characterized by a **milder clinical course** compared to idiopathic SLE. - Symptoms often resolve following cessation of the offending drug. *Presence of renal or CNS disease is rare* - **Major organ involvement**, such as severe **renal** (nephritis) or **central nervous system (CNS)** disease, is rare in drug-induced lupus. - These severe manifestations are characteristic of idiopathic SLE [1]. *Hypocomplementemia is less common* - **Hypocomplementemia** (low C3 and C4 levels) is a common finding in active idiopathic SLE, reflecting immune complex activity. - In contrast, **drug-induced lupus** typically presents with normal complement levels.

Q: A person presents with recurrent swelling on the face and lips due to emotional stress. The likely cause is?

C1 esterase inhibitor deficiency. C1 esterase inhibitor deficiency - This condition presents with recurrent episodes of angioedema (swelling of face, lips, airway, or gastrointestinal tract) that are often triggered by stress, trauma, or medical procedures. - The deficiency leads to unregulated activation of the complement and kallikrein-kinin pathways, resulting in excessive bradykinin production which causes increased vascular permeability and swelling. Allergy - Allergic reactions typically involve hives (urticaria) and itching, which are usually absent in C1 esterase inhibitor deficiency. - Allergic angioedema is often mediated by histamine and resolves with antihistamines or epinephrine, which are ineffective in C1 esterase inhibitor deficiency [2]. Anaphylaxis - Anaphylaxis is a severe, life-threatening allergic reaction that includes symptoms such as respiratory distress, hypotension, and generalized urticaria, in addition to angioedema [2]. - While angioedema can be a feature, the constellation of symptoms and the common triggers differ significantly from C1 esterase inhibitor deficiency [2]. ACE inhibitor-induced angioedema - This type of angioedema is a known side effect of ACE inhibitor medications and usually occurs after beginning the medication [1]. - It is also caused by increased bradykinin levels but is directly linked to the drug's action, not an underlying genetic deficiency, and typically resolves upon discontinuation of the medication.

Q: Which type of arthritis is commonly associated with tarsal tunnel syndrome?

Rheumatoid arthritis. Rheumatoid arthritis (RA) is a systemic inflammatory disease that can lead to synovitis and inflammation of tendons, which can compress the posterior tibial nerve in the tarsal tunnel [1]. The chronic inflammation and proliferation of the synovial tissue around the ankle can directly impinge on the nerve, causing tarsal tunnel syndrome [1]. *Ankylosing spondylitis* - This is a chronic inflammatory disease primarily affecting the axial skeleton, particularly the spine and sacroiliac joints. - While it can have peripheral manifestations, it does not typically cause tarsal tunnel syndrome through direct nerve compression from inflammation in the ankle joint. *Osteoarthritis* - Osteoarthritis (OA) is a degenerative joint disease characterized by cartilage breakdown and bone spur formation. - While OA can affect the ankle, it is less directly associated with the inflammatory changes that lead to tarsal tunnel syndrome compared to RA. *Psoriatic arthritis* - Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis, often involving joints of the hands, feet, and spine. - Although PsA can cause inflammation in the foot and ankle, it is not as commonly linked to tarsal tunnel syndrome as rheumatoid arthritis.

Q: Normal CRP with elevated ESR is seen in:

SLE. ***SLE*** - In **Systemic Lupus Erythematosus (SLE)**, the **ESR** is often significantly elevated due to hypergammaglobulinemia and increased fibrinogen, reflecting systemic inflammation [2]. - However, the **CRP** may be normal or only mildly elevated, which is a distinguishing feature compared to other inflammatory conditions [1], [2]. *RA* - In **Rheumatoid Arthritis (RA)**, both **CRP and ESR** are typically elevated, reflecting the acute phase response due to active inflammation. - An isolated elevated ESR with a normal CRP is less common in active RA and would prompt consideration of alternative or co-existing conditions. *Scleroderma* - For **Scleroderma (Systemic Sclerosis)**, the **ESR and CRP** are often normal or only mildly elevated, even in the presence of extensive organ involvement [1]. - Significant elevations in both ESR and CRP should prompt a search for alternative diagnoses or complications such such as an infection. *Polymyalgia rheumatica* - **Polymyalgia Rheumatica (PMR)** is characterized by marked inflammation, leading to a **significantly elevated ESR and CRP** [2]. - A normal CRP with an elevated ESR would be atypical for PMR, which is primarily diagnosed based on clinical symptoms and this distinct inflammatory marker pattern.

Question 1

Which is the rheumatoid arthritis autoantibody?

Accepted Answer

Anti CCP

Answer

Anti DLE

Answer

Anti ds DNA

Answer

Anti histone

Question 2

Which of the following conditions is least likely to present with polyarticular involvement in clinical practice?

Accepted Answer

Gout

Answer

Psoriatic arthritis

Answer

SLE

Answer

Ankylosing spondylitis

Question 3

Most common pulmonary manifestation of SLE is which of the following?

Accepted Answer

Pleuritis

Answer

Shrinking Lung

Answer

Interstitial inflammation

Answer

Intra alveolar hemorrhage

Question 4

Bilateral hilar lymphadenopathy, along with non-caseating granulomas, is a characteristic feature of:

Accepted Answer

Sarcoidosis

Answer

Scleroderma

Answer

SLE

Answer

Stein-leventhal syndrome

Question 5

A 20-year-old female has an erythematous rash over her face, including both cheeks and the bridge of her nose, which is exacerbated by sunlight exposure when she is outdoors. In addition to the rash, she has experienced muscle and joint pain for several months. Although radiographs of the joints do not reveal any abnormalities, she has normal joint mobility without deformity. Which laboratory test finding is most characteristic of systemic lupus erythematosus (SLE)?

Accepted Answer

Antibodies to double-stranded DNA

Answer

Elevated anti-streptolysin 0 (ASO) titer

Answer

HLA-B27 genotype

Answer

Markedly decreased serum level of immunoglobulin G (IgG)

Question 6

In ankylosing spondylitis, joint involvement is least in?

Accepted Answer

Wrist and hand

Answer

Costochondral junction

Answer

Sacroiliac joint

Answer

Acromio-clavicular joint

Question 7

All of the following are true about Drug-Induced Lupus in comparison to Idiopathic SLE, except:

Accepted Answer

More common in females

Answer

Hypocomplementemia is less common

Answer

Milder disease

Answer

Presence of renal or CNS disease is rare

Question 8

A person presents with recurrent swelling on the face and lips due to emotional stress. The likely cause is?

Accepted Answer

C1 esterase inhibitor deficiency

Answer

Allergy

Answer

Anaphylaxis

Answer

ACE inhibitor-induced angioedema

Question 9

Which type of arthritis is commonly associated with tarsal tunnel syndrome?

Accepted Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Question 10

Normal CRP with elevated ESR is seen in:

Accepted Answer

SLE

Answer

RA

Answer

Polymyalgia rheumatica

Answer

Scleroderma

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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