Joints and Rheumatologic Diseases — MCQs
Bamboo spine with sacroilitis -
All are features of seronegative spondyloarthropathies except -
Seronegative spondarthritides includes all EXCEPT
Bony erosions are seen in the following except -
A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?
Which of the following is seen in Rheumatoid Arthritis?
According to "rule of nines", burns involving perineum are:
Which joint is LEAST commonly affected in early rheumatoid arthritis?
Which of the following soft-tissue lesions has a biphasic histologic pattern and consists of cuboidal epithelial and spindle-shaped mesenchymal cells?
Albers-Schönberg disease is:
Joints and Rheumatologic Diseases Indian Medical PG Practice Questions and MCQs
Question 1: Bamboo spine with sacroilitis -
- A. Psoriatic arthritis
- B. Ankylosing spondylitis (Correct Answer)
- C. OA
- D. RA
Explanation: ***Ankylosing spondylitis*** - **Bamboo spine** is a classic radiographic finding in advanced **ankylosing spondylitis**, resulting from ossification of the anulus fibrosus and spinal ligaments [1]. - **Sacroiliitis**, inflammation of the sacroiliac joints, is another hallmark feature and often the earliest radiographic sign of the disease [1], [3]. *Psoriatic arthritis* - While psoriatic arthritis can involve the spine and cause sacroiliitis, it typically presents with **asymmetric involvement** [2] and is less commonly associated with the widespread, progressive ossification characteristic of true "bamboo spine" [4]. - It often also involves **skin psoriasis** and **nail changes**, which are not indicated as the primary finding here [4]. *OA* - **Osteoarthritis (OA)** is a degenerative joint disease characterized by cartilage loss and osteophyte formation, often seen in weight-bearing joints and the spine [2]. - While OA can affect spinal joints and cause stiffness, it does **not cause inflammatory sacroiliitis** or the specific syndesmophyte formation that leads to "bamboo spine." *RA* - **Rheumatoid arthritis (RA)** primarily affects peripheral joints, particularly small joints of the hands and feet, and typically spares the sacroiliac joints and the thoracolumbar spine [2]. - Spinal involvement in RA is usually limited to the **cervical spine**, leading to atlantoaxial subluxation, and does not cause "bamboo spine" or widespread sacroiliitis.
Question 2: All are features of seronegative spondyloarthropathies except -
- A. RA factor positive (Correct Answer)
- B. Uveitis
- C. Occur in young age
- D. HLA-B27 positive
Explanation: ***RA factor positive*** - Seronegative spondyloarthropathies are specifically defined by the **absence of rheumatoid factor (RF)** in the blood. - Therefore, a positive RA factor would exclude a diagnosis of seronegative spondyloarthropathy. *Uveitis* - **Uveitis**, particularly **anterior uveitis**, is a common extra-articular manifestation of several seronegative spondyloarthropathies, such as ankylosing spondylitis and reactive arthritis [1]. - Its presence is a characteristic feature, not an exclusion criterion. *Occur in young age* - Seronegative spondyloarthropathies, such as **ankylosing spondylitis** and **reactive arthritis**, typically present in younger individuals, often before the age of 40. - This is a distinguishing feature compared to other arthropathies that might manifest later in life. *HLA-B27 positive* - **HLA-B27 positivity** is a strong genetic association with many seronegative spondyloarthropathies, particularly ankylosing spondylitis and reactive arthritis [1]. - While not universally present in all cases, it is a hallmark feature that aids in diagnosis [2].
Question 3: Seronegative spondarthritides includes all EXCEPT
- A. Reiter's syndrome
- B. Rheumatoid arthritis (Correct Answer)
- C. Ankylosing spondylitis
- D. Psoriatic arthritis
Explanation: ***Rheumatoid arthritis*** - Rheumatoid arthritis (RA) is characterized by the presence of **rheumatoid factor (RF)** and/or **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, making it a **seropositive** arthropathy. [1] - While it causes an inflammatory arthritis, its serological markers differentiate it from the seronegative spondyloarthropathies. *Reiter's syndrome* - Reiter's syndrome, now commonly referred to as **reactive arthritis**, is a classic example of a seronegative spondyloarthropathy. [1] - It is often triggered by an infection and is typically **RF-negative** and **HLA-B27 positive**. *Ankylosing spondylitis* - **Ankylosing spondylitis (AS)** is a prototypical seronegative spondyloarthropathy, characterized by inflammation primarily affecting the **spine and sacroiliaciac joints**. [1] - It is defined by the **absence of RF** and **anti-CCP antibodies**, though it is strongly associated with **HLA-B27**. *Psoriatic arthritis* - **Psoriatic arthritis (PsA)** is another member of the seronegative spondyloarthropathies, occurring in individuals with **psoriasis**. [1] - Like other conditions in this group, patients with PsA are typically **negative for RF** and **anti-CCP antibodies**.
Question 4: Bony erosions are seen in the following except -
- A. Psoriasis
- B. Osteoarthritis
- C. Gout
- D. SLE (Correct Answer)
Explanation: ***SLE*** - **Systemic Lupus Erythematosus (SLE)** is primarily a connective tissue disease characterized by inflammation, but it typically causes **non-erosive arthritis** [1]. - While joint pain and inflammation are common, **bony erosions** are a classic feature of inflammatory arthropathies like rheumatoid arthritis or spondyloarthropathies, not SLE [1]. *Psoriasis* - **Psoriatic arthritis**, a form of spondyloarthritis associated with psoriasis, frequently causes **bony erosions**, particularly in the small joints of the hands and feet [1]. - It can also lead to characteristic radiographic changes like the "**pencil-in-cup**" deformity and periostitis [1]. *Osteoarthritis* - **Osteoarthritis** is characterized by cartilage degradation, but it can lead to **subchondral bone erosions** in advanced stages, particularly in severely affected joints. - These erosions are often accompanied by **osteophytes** and **subchondral sclerosis**. *Gout* - **Gout** is caused by the deposition of urate crystals, which can lead to characteristic **bony erosions** known as "punched-out" lesions or **tophi** on radiographs [2]. - These erosions often have an **overhanging edge** appearance, particularly around the affected joints.
Question 5: A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?
- A. Soft tissue swelling at the proximal interphalangeal joint
- B. Articular erosions on X-ray (Correct Answer)
- C. Elevated ESR
- D. Juxta articular osteoporosis on X-ray
Explanation: ***Articular erosions on X-ray*** - Articular erosions are classic radiographic hallmarks of **rheumatoid arthritis (RA)**, indicating destructive changes to cartilage and bone [1]. - While both RA and **Systemic Lupus Erythematosus (SLE)** can cause polyarthritis, erosive disease is characteristic of RA and generally absent in SLE [1]. *Soft tissue swelling at the proximal interphalangeal joint* - **Soft tissue swelling** can occur in both RA and SLE due to inflammation, making it a non-specific finding for differentiation [2]. - Both conditions frequently affect the **proximal interphalangeal (PIP) joints**, causing swelling and tenderness [2]. *Elevated ESR* - An **elevated Erythrocyte Sedimentation Rate (ESR)** is a general marker of inflammation and can be high in both RA and SLE [3]. - It reflects ongoing disease activity but does not help to distinguish between these two specific autoimmune conditions. *Juxta articular osteoporosis on X-ray* - **Juxta-articular osteoporosis** can be seen in both RA due to regional bone loss from inflammation and in SLE, often as a side effect of corticosteroid use. - This finding is therefore not specific enough to definitively differentiate between RA and SLE.
Question 6: Which of the following is seen in Rheumatoid Arthritis?
- A. Presence of Rheumatoid Factor (RF)
- B. Presence of Anti-CCP antibodies
- C. Higher risk of extra-articular manifestations
- D. All of the above (Correct Answer)
Explanation: ***All of the above*** - **Rheumatoid arthritis** is an autoimmune disease characterized by chronic inflammation that can affect various body systems, and the presence of **Rheumatoid Factor (RF)**, **Anti-Cyclic Citrullinated Peptide (Anti-CCP) antibodies**, and a **higher risk of extra-articular manifestations** are all characteristic features [1]. - While RF and anti-CCP are diagnostic markers, extra-articular manifestations highlight the systemic nature of the disease, affecting organs beyond the joints. *Presence of Rheumatoid Factor (RF)* - While many patients with **rheumatoid arthritis** test positive for **RF**, it is not specific to RA and can be seen in other conditions, such as systemic lupus erythematosus, Sjögren's syndrome, and chronic infections [1]. - Approximately 20% of RA patients are seronegative for RF. *Presence of Anti-CCP antibodies* - **Anti-CCP antibodies** are highly specific for **rheumatoid arthritis** and often appear early in the disease course, making them a valuable diagnostic and prognostic marker [1]. - Their presence is strongly associated with an erosive disease course. *Higher risk of extra-articular manifestations* - **Extra-articular manifestations** of **rheumatoid arthritis** indicate systemic involvement and can include rheumatoid nodules, vasculitis, pleuritis, pericarditis, scleritis, and Felty's syndrome [1]. - The presence of these manifestations often correlates with more severe disease and a poorer prognosis [1].
Question 7: According to "rule of nines", burns involving perineum are:
- A. 27%
- B. 18%
- C. 9%
- D. 1% (Correct Answer)
Explanation: ***Correct: 1%*** - According to the **rule of nines**, the **perineum** (genital region) is allocated **1%** of the total body surface area (TBSA). - This specific percentage is used for calculating burn extent, particularly relevant for fluid resuscitation in adults. - This is a standard component of the rule of nines used in burn assessment. *Incorrect: 27%* - This percentage is inaccurate for any single anatomical region in the standard adult **rule of nines** calculation. - It would represent a combination of large body areas, such as the entire back and one arm, or combinations of multiple regions. *Incorrect: 18%* - In the **rule of nines**, **18%** is assigned to an **entire lower limb** (front and back) or the **entire back** or **entire front of the trunk**. - The perineum is a much smaller area and does not account for this large a percentage. *Incorrect: 9%* - According to the **rule of nines**, **9%** is assigned to an **entire upper limb** (arm) or the **head and neck** region (adult). - The perineum is a considerably smaller area and is not assigned this proportion.
Question 8: Which joint is LEAST commonly affected in early rheumatoid arthritis?
- A. Knee
- B. Ankle
- C. Tarsometatarsal (Correct Answer)
- D. Metatarsophalangeal
Explanation: ***Tarsometatarsal*** - The **tarsometatarsal joints** (Lisfranc joints) are deep within the foot and are relatively protected, making them less commonly involved in early RA. - While other foot joints like the metatarsophalangeal joints are frequently affected, the tarsometatarsals typically show involvement only in **advanced or severe disease**. *Knee* - The knee is a **large weight-bearing joint** that can be affected in RA but is less frequently involved in the **very early stages** compared to smaller joints [1]. - Though not a primary initial target, **synovitis and effusions** can develop as the disease progresses. *Ankle* - The ankle joint can be involved in RA, but it is **less common than the small joints of the hands and feet** in early disease [1]. - When affected, it typically presents with **pain, swelling, and stiffness**, impacting gait. *Metatarsophalangeal* - The **metatarsophalangeal (MTP) joints** are very commonly affected in early rheumatoid arthritis due to their synovial lining and frequent use [1]. - Involvement here often leads to **pain, swelling, and difficulty walking**, being a significant diagnostic criterion [2].
Question 9: Which of the following soft-tissue lesions has a biphasic histologic pattern and consists of cuboidal epithelial and spindle-shaped mesenchymal cells?
- A. Synovial sarcoma (Correct Answer)
- B. Nodular fasciitis
- C. Liposarcoma
- D. Malignant fibrous histiocytoma
Explanation: *Liposarcoma* - Typically presents with **lipoblasts** and does not exhibit a **biphasic histologic pattern**. - Usually lacks **cuboidal epithelial** cells, focusing instead on adipose tissue differentiation. *Nodular fasciitis* [2] - This is a reactive benign lesion characterized by **plump fibroblasts** and **myofibroblasts**, not a malignant neoplasm. - The histological pattern is **monophonic** and does not feature **epithelial components**. *Synovial sarcoma* [1] - Though it can present with a biphasic pattern, it is characterized by **monomorphic spindle cells** and does not consistently show **epithelial components** like cuboidal cells. - Typically associated with **SS18-SSX fusion** genes, which is not an indication of just any malignant neoplasm. *Malignant fibrous histiocytoma* - Characterized by **histiocytic and spindle cell** components but lacks the **epithelial features** that define a biphasic pattern. - Primarily composed of **malignant fibrous histiocytoma**, which does not indicate a specific malignancy associated with epithelial differentiation. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1225-1226. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1223-1224.
Question 10: Albers-Schönberg disease is:
- A. Osteoporosis
- B. Paget
- C. Osteogenesis imperfecta
- D. Osteopetrosis (Correct Answer)
Explanation: ***Osteopetrosis*** - **Albers-Schönberg disease** is another name for **osteopetrosis**, also known as **marble bone disease** [1]. - It is a group of rare genetic disorders characterized by abnormally **dense bones** due to a defect in **osteoclast** function, leading to impaired bone resorption [1]. *Osteoporosis* - **Osteoporosis** is characterized by decreased bone density and structural deterioration of bone tissue, leading to an increased risk of fractures. - It results from an imbalance where **bone resorption outpaces bone formation**, the opposite of osteopetrosis. *Paget* (Paget's disease of bone) - **Paget's disease of bone** involves localized areas of increased bone turnover, leading to disorganized bone remodeling and weakened, enlarged bones. - It is distinct from osteopetrosis, which involves a generalized increase in bone density. *Osteogenesis imperfecta* - **Osteogenesis imperfecta** (OI), or brittle bone disease, is a genetic disorder causing extremely fragile bones prone to fractures, often due to defects in **collagen production** [1]. - This condition presents with bone fragility and often blue sclera, which is the opposite of the increased bone density seen in osteopetrosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1188-1189.
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