Rheumatology and Immunology Practice Questions

Q: What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Increase in titre of anti-dsDNA. In Systemic Lupus Erythematosus (SLE), monitoring disease activity is crucial for managing flares. The correct answer is **Option A: Increase in titre of anti-dsDNA**. ### **Why Anti-dsDNA is the Correct Answer** Anti-dsDNA antibodies are highly specific for SLE and their levels correlate directly with disease activity. A rising titre often precedes a clinical flare, particularly **Lupus Nephritis** [1]. When these antibodies increase, they form immune complexes that activate the complement system, leading to a simultaneous **decrease in C3 and C4 levels** [1]. This "rising anti-dsDNA and falling complement" pattern is the classic laboratory hallmark of an SLE flare. ### **Why Other Options are Incorrect** * **B. Increase in titre of ANA:** ANA is the best screening test (high sensitivity) but is useless for monitoring flares [1]. Once positive, the titre does not reliably correlate with disease severity or activity. * **C. Increase in anti-Sm:** Anti-Smith antibodies are the most specific for SLE, but like ANA, their levels remain relatively constant and do not fluctuate with disease activity [1]. * **D. Elevation of ESR:** While ESR is often raised in SLE, it is a non-specific marker of inflammation. It can be elevated due to infections or other co-morbidities, making it less reliable than anti-dsDNA for confirming a lupus-specific flare [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **Most Sensitive Test:** ANA (95-98%) [1]. * **Most Specific Test:** Anti-Sm (followed by anti-dsDNA) [1]. * **Drug-Induced Lupus:** Anti-Histone antibodies are the marker of choice. * **Neonatal Lupus/Sjogren’s:** Associated with Anti-Ro (SS-A) and Anti-La (SS-B) [1]. * **Active Nephritis Profile:** ↑ Anti-dsDNA + ↓ Complement (C3, C4) [1].

Q: Which is NOT a feature of polymyositis?

Gottron's rash. **Explanation:** The correct answer is **Gottron’s rash** because it is a pathognomonic cutaneous feature of **Dermatomyositis**, not Polymyositis [1]. While both conditions share similar patterns of muscle involvement, Polymyositis (PM) is strictly an inflammatory myopathy without primary skin manifestations. **Analysis of Options:** * **Gottron's rash (Correct):** These are erythematous, scaly eruptions over the dorsal aspects of the MCP and IP joints [1], [2]. Along with the Heliotrope rash, it distinguishes Dermatomyositis from Polymyositis [2]. * **Proximal muscle involvement:** This is the hallmark of PM. Patients typically present with symmetrical weakness of the shoulder and pelvic girdles (e.g., difficulty climbing stairs or combing hair) [1]. * **Pharyngeal muscle involvement:** In severe cases of PM, the striated muscles of the upper esophagus and pharynx are involved, leading to dysphagia and an increased risk of aspiration pneumonia [1]. * **Pain in limbs:** While the primary symptom is weakness, approximately 25-50% of patients with PM report muscle tenderness or myalgia during the acute phase [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Immunopathology:** PM is mediated by **CD8+ T-cells** (endomysial inflammation), whereas Dermatomyositis is mediated by **CD4+ T-cells and B-cells** (perifascicular atrophy). * **Antibodies:** **Anti-Jo-1** is the most common myositis-specific antibody and is strongly associated with **Interstitial Lung Disease (ILD)** and "Mechanic's hands" [1]. * **Malignancy:** Both are associated with increased cancer risk, but the risk is significantly higher in Dermatomyositis [2]. * **Diagnosis:** Gold standard is a **Muscle Biopsy**; initial screening involves elevated **CPK levels** [2].

Q: Which among the following is true about Caplan's syndrome?

Pneumoconiosis with rheumatoid arthritis. **Explanation:** **Caplan’s Syndrome** (also known as Rheumatoid Pneumoconiosis) is a clinical entity characterized by the development of specific pulmonary nodules in patients with **Pneumoconiosis** (most commonly Coal Worker's Pneumoconiosis, but also Silicosis or Asbestosis) [1] who also have **Rheumatoid Arthritis (RA)** [2]. 1. **Why Option D is Correct:** The syndrome represents an exaggerated inflammatory response in the lungs. In patients with a rheumatoid diathesis, the inhalation of inorganic dust triggers the formation of multiple, well-defined "Caplan nodules" (0.5 to 5 cm in diameter). These nodules are histologically similar to subcutaneous rheumatoid nodules but occur within the lung parenchyma, typically on a background of mild pneumoconiosis [1]. 2. **Why Other Options are Incorrect:** * **Option A:** While pneumoconiosis (like Silicosis) can cause hilar lymphadenopathy (e.g., "egg-shell calcification"), this is a feature of the primary disease, not Caplan’s syndrome [1]. * **Option B:** Congestive cardiac failure is not a defining component of this syndrome, though chronic lung disease can eventually lead to Cor Pulmonale. * **Option C:** There is no specific association between Caplan’s syndrome and HIV. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Look for multiple, bilateral, peripheral "crop-like" nodules that may appear suddenly. * **Serology:** Patients are typically **Rheumatoid Factor (RF) positive**. * **Timing:** Pulmonary nodules can appear before, during, or after the onset of clinical arthritis [2]. * **Differential:** Must be distinguished from **Erasmus Syndrome**, which is the association of Silicosis with Systemic Sclerosis (Scleroderma).

Q: What is the most common pattern of joint involvement in psoriatic arthropathy?

Asymmetrical inflammatory oligoarthritis. **Explanation:** Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy associated with psoriasis, classified under seronegative spondyloarthropathies [1]. **1. Why Option D is Correct:** Historically and classically, **Asymmetrical inflammatory oligoarthritis** is considered the most common pattern of involvement (occurring in approximately 70% of cases). It typically involves a few large joints (like the knee) along with one or two small joints of the fingers or toes, often presenting with a characteristic "sausage digit" (dactylitis). **2. Analysis of Incorrect Options:** * **Option A (Psoriatic spondylitis):** This involves the axial skeleton (sacroiliitis and spondylitis). While high-yield, it occurs in only about 5–20% of patients and is rarely the presenting feature [1]. * **Option B (Arthritis mutilans):** This is the most severe but **least common** form (<5%). It involves extensive bone resorption (osteolysis) leading to "telescoping fingers" [1] and the "pencil-in-cup" appearance on X-ray. * **Option C (Symmetrical polyarthritis):** This pattern mimics Rheumatoid Arthritis (RA) but is Rheumatoid Factor (RF) negative. While some modern studies suggest its prevalence is rising, traditional teaching and standard textbooks (like Harrison’s) still prioritize asymmetrical oligoarthritis as the most frequent pattern for examination purposes. **3. NEET-PG High-Yield Pearls:** * **DIP Joint Involvement:** PsA is one of the few inflammatory remains that involves the Distal Interphalangeal (DIP) joints [1]. * **Nail Changes:** Pitting, onycholysis, and hyperkeratosis are strongly associated with the development of PsA [1]. * **Radiology:** Look for the **"Pencil-in-cup" deformity** and "Gull-wing" appearance. * **HLA Association:** Strongly linked with **HLA-B27** (especially in the spondylitis variant) [1].

Question 1

A 32-year-old woman presents 6 months after rhinoplasty with a saddle nose deformity. Biopsy shows granulomatous inflammation. What is the most appropriate immediate management?

Accepted Answer

Start oral corticosteroids and investigate for systemic disease

Answer

Immediate revision rhinoplasty with cartilage graft

Answer

Perform immediate debridement of necrotic tissue

Answer

Prescribe topical antibiotics and observe

Question 2

What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Increase in titre of anti-dsDNA

Answer

Increase in titre of ANA

Answer

Increase in anti-Sm

Answer

Elevation of ESR

Question 3

Which is NOT a feature of polymyositis?

Accepted Answer

Gottron's rash

Answer

Pharyngeal muscle involvement

Answer

Proximal muscle involvement

Answer

Pain in limbs

Question 4

Which among the following is true about Caplan's syndrome?

Accepted Answer

Pneumoconiosis with rheumatoid arthritis

Answer

Pneumoconiosis with lymphadenopathy

Answer

Pneumoconiosis with congestive cardiac failure

Answer

Pneumoconiosis with HIV

Question 5

What is the most common pattern of joint involvement in psoriatic arthropathy?

Accepted Answer

Asymmetrical inflammatory oligoarthritis

Answer

Psoriatic spondylitis

Answer

Arthritis mutilans

Answer

Symmetrical polyarthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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