Rheumatology and Immunology Practice Questions

Q: A 35-year-old patient presents with colicky abdominal pain, joint pain, and palpable purpura. Urinalysis shows only red blood cells with no other significant findings. Which of the following is the likely diagnosis?

IgA vasculitis. ***IgA vasculitis***- The presentation of **palpable purpura**, **colicky abdominal pain**, and **joint pain** (arthralgia/arthritis), along with evidence of renal disease (**hematuria**), is the classic tetrad of **IgA vasculitis** (Henoch-Schönlein purpura) [1]. - This condition involves deposits of **IgA-containing immune complexes** in the walls of small vessels across various organ systems, including the skin, joints, gastrointestinal tract, and kidneys [1]. *Granulomatosis with polyangiitis* - This primarily affects the **upper and lower respiratory tract** (e.g., sinus inflammation, pulmonary nodules/hemorrhage) and the kidneys, often presenting without classic palpable purpura. - It is strongly associated with circulating **c-ANCA** antibodies targeting proteinase 3 (PR3). *Microscopic polyangiitis* - This is a non-necrotizing small-vessel vasculitis [2] typically presenting with **rapidly progressive glomerulonephritis** and often pulmonary capillary involvement causing hemorrhage. - It is usually associated with **p-ANCA** antibodies targeting myeloperoxidase (MPO) and rarely causes the prominent skin and GI symptoms seen here. *Behçet's disease* - The cardinal features of Behçet’s disease are recurrent **oral aphthous ulcers**, **genital ulcers**, and **ocular inflammation** (uveitis). - While it can cause vasculitis, it primarily involves large veins and arteries, and the combination of palpable purpura and colicky pain strongly favors IgA vasculitis over this diagnosis.

Q: A 17-year-old woman with no comorbidities presents with numbness and paraesthesia of the fingers along with the characteristic finding as shown in the image below. She has no history of smoking or history of other illnesses. She mentions the episodes occur when she is under excess stress or during cold temperatures. What is the most likely diagnosis?

a. Raynaud's phenomenon. ***Raynaud's phenomenon*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical picture of episodic digital **numbness**, paraesthesia, and color changes specifically triggered by **cold temperatures** or **stress** is pathognomonic for Raynaud's phenomenon. - Given the patient's young age (17) and lack of underlying illness (no comorbidities), this is strongly suggestive of **Primary Raynaud's phenomenon** (Raynaud's disease). *Buerger's disease* - **Buerger's disease** (Thromboangiitis obliterans) is highly associated with heavy **tobacco use**, which conflicts with the patient's history of no smoking. - This condition involves inflammation and thrombosis of medium and small arteries, typically leading to more severe fixed ischemia, ulcers, and **gangrene**, rather than transient vasospastic episodes. *Atherosclerosis* - **Atherosclerosis** is a fixed obstruction due to plaque buildup and is extremely rare in a healthy, young 17-year-old patient. - When present, it causes symptoms like **intermittent claudication** or rest pain, which are constant and exertional, unlike the acute, episodic nature of vasospasm. *Peripheral arterial disease* - **Peripheral arterial disease (PAD)** typically refers to occlusive disease (often atherosclerotic) that leads to reduced blood flow, causing symptoms that worsen with **exertion**. - Unlike Raynaud's, PAD does not typically cause acute, reversible, triphasic color changes in response to **cold** or emotional stress.

Q: A 50-year-old woman presented with difficulty in activities like climbing stairs, getting up from a chair, and combing hair. Violaceous erythema of the upper eyelids was noted. What is the most probable diagnosis?

Dermatomyositis. ***Dermatomyositis***- The combination of **proximal muscle weakness** (difficulty climbing stairs, rising from a chair, combing hair) and the pathognomonic **Heliotrope sign** (violaceous erythema of the upper eyelids) is highly indicative of **Dermatomyositis** [1], [2].- Dermatomyositis is a type of idiopathic inflammatory **myopathy** that also features characteristic skin findings like **Gottron papules** (over MCPs, PIPs, and elbows) [1], [2].*Inclusion body myositis*- Primarily affects men older than 50 and often involves **distal muscle weakness** (e.g., finger flexors) in addition to proximal muscles, which is not described here [3].- Characterized by early loss of **deep tendon reflexes** and may show **rimmed vacuoles** on muscle biopsy, features distinct from this presentation [3].*Polymyositis*- Presents with similar **proximal muscle weakness** but **lacks the characteristic skin manifestations** like the Heliotrope sign or Gottron papules [1].- Diagnosis is supported by elevated muscle enzymes (CK) and inflammatory changes on muscle biopsy, but the absence of skin findings rules it out in favor of dermatomyositis.*Scleroderma*- Characterized by **skin thickening** and **fibrosis**, often involving the hands and face, and potentially internal organs (lung, GI tract).- Muscle weakness, if present (**Myositis overlap**), is usually less prominent than the distinctive **cutaneous and systemic features** of scleroderma.

Q: A 50-year-old female patient with a known case of ovarian cancer presents with difficulty in activities like climbing stairs, getting up from a chair, combing hair, etc. The following characteristic sign was found on examination. The most probable diagnosis is:

Dermatomyositis. ***Dermatomyositis*** - This diagnosis is strongly suggested by the combination of **symmetric proximal muscle weakness** (difficulty climbing stairs, combing hair) and the characteristic **Shawl sign**, an erythematous rash over the shoulders, neck, and upper back as shown in the image. - Dermatomyositis is a well-known **paraneoplastic syndrome**, frequently associated with underlying malignancies, particularly **ovarian cancer** in women, which aligns perfectly with the patient's history. *Systemic lupus erythematosus* - The classic cutaneous feature of SLE is a **malar rash** (butterfly rash) on the face; while other photosensitive rashes can occur, the Shawl sign is more specific to dermatomyositis. - Although SLE can present with myositis, the strong association with an underlying ovarian cancer makes dermatomyositis a more probable diagnosis. *Systemic sclerosis* - The primary feature of systemic sclerosis is **widespread fibrosis** and thickening of the skin (**scleroderma**), typically starting in the fingers (**sclerodactyly**), which is not described. - Muscle weakness in systemic sclerosis is usually due to disuse atrophy or fibrosis rather than a primary inflammatory myopathy, and it does not present with the rash seen. *Cushing syndrome* - While Cushing syndrome can cause **proximal muscle weakness** due to steroid myopathy, its characteristic skin findings include **violaceous striae**, easy bruising, and plethora, not a Shawl sign. - The inflammatory nature of the rash seen in the image is inconsistent with the endocrine and metabolic changes of Cushing syndrome.

Q: An elderly patient with the following deformity was brought to the OPD. What is the most probable diagnosis? ![img-13.jpeg](img-13.jpeg)

Rheumatoid arthritis. ***Rheumatoid arthritis*** - The image displays classic deformities of advanced **rheumatoid arthritis**, including **ulnar deviation** of the fingers at the metacarpophalangeal (MCP) joints and swelling, which are characteristic of this condition. - The presence of a subcutaneous nodule over the olecranon process (elbow) is highly suggestive of a **rheumatoid nodule**, a common extra-articular manifestation of the disease. *Rickets* - Rickets is a disease of **children** caused by defective mineralization of growing bone, typically due to **vitamin D deficiency**. This patient is described as elderly. - It presents with skeletal deformities like **bowed legs (genu varum)** and **rachitic rosary**, not the specific erosive small joint arthritis seen in the image. *Osteomalacia* - Osteomalacia is the adult counterpart of rickets, characterized by softening of bones. It typically causes diffuse **bone pain**, muscle weakness, and fractures rather than joint deformities. - It does not cause the **inflammatory synovitis** and characteristic joint erosions that lead to the deformities seen in rheumatoid arthritis. *Osteoarthritis* - Osteoarthritis is a **degenerative** joint disease that typically affects the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, leading to **Heberden's** and **Bouchard's nodes**, while characteristically sparing the MCP joints. - It lacks the systemic inflammatory features and does not cause **ulnar deviation** or **rheumatoid nodules**.

Q: A 35-year-old female presents with symmetrical joint pain and morning stiffness lasting 2 hours involving small joints of hands for 6 months. Examination reveals swelling of metacarpophalangeal and proximal interphalangeal joints bilaterally. ESR is 55 mm/hr, CRP is elevated, and rheumatoid factor is positive. X-ray shows periarticular osteopenia. What is the most appropriate initial treatment?

Methotrexate with folic acid supplementation. Detailed treatment strategies for Rheumatoid Arthritis (RA) include: *Methotrexate* - **Methotrexate (MTX)** is the **first-line anchor drug** for treating moderate-to-severe established **Rheumatoid Arthritis (RA)** due to its efficacy in controlling symptoms and preventing joint damage [1]. - It is a **Disease-Modifying Anti-Rheumatic Drug (DMARD)**, effective in managing the characteristic symmetrical polyarthritis and elevated inflammatory markers seen in this patient. *Prednisolone* - **Glucocorticoids** like Prednisolone are primarily used as **bridge therapy** to control acute inflammation and symptoms when initiating slower-acting DMARDs like MTX [1]. - They are not considered the most appropriate **initial definitive treatment** alone, as long-term use is associated with significant side effects. *Etanercept* - **Etanercept** (a TNF-alpha inhibitor) is a **biologic DMARD**, which is typically reserved for patients who have had an **inadequate response** (failure) to conventional DMARDs like methotrexate [1]. - Initiating biologics as the first line is usually not justified unless the disease is highly aggressive or there are contraindications to conventional DMARDs [1]. *Hydroxychloroquine* - **Hydroxychloroquine (HCQ)** is a milder DMARD, generally preferred for patients with **early, mild, non-erosive RA** or as a combination therapy. - It is less effective than methotrexate for established, seropositive RA with significant inflammation (ESR 55 mm/hr, positive RF) and radiographic changes (periarticular osteopenia).

Q: A patient with rheumatoid arthritis presents with neck pain and clinical signs of myelopathy. What is the most likely diagnosis?

Atlantoaxial dislocation. ***Atlantoaxial dislocation*** - **Rheumatoid arthritis (RA)** frequently affects the cervical spine, particularly the atlantoaxial joint, leading to **subsidence** of the atlas (C1) on the axis (C2). - **Atlantoaxial dislocation (AAD)** results in **spinal cord compression** (myelopathy) due to narrowing of the spinal canal, presenting as neck pain and neurological signs [1]. ***Osteoarthritis of vertebrae*** - While osteoarthritis causes neck pain, it is not the typical cause of **acute myelopathy** in RA patients. - Osteoarthritis usually affects the **lower cervical spine** and lacks the inflammatory destruction characteristic of RA involvement in the C1-C2 facets [2]. ***C2-C3 intervertebral stenosis*** - Stenosis typically involves the **lower cervical levels** (C5-C7) caused by osteophyte formation or disc disease, which is less common in RA [2]. - The hallmark **RA involvement** causing myelopathy is specifically **atlantoaxial subluxation** (dislocation). ***Disc herniation*** - Disc herniation is a common cause of radiculopathy and sometimes myelopathy in the general population, but it is **not the primary mechanism** of cervical myelopathy in RA. - The major instability and subsequent cord compression in RA patients occur due to **ligamentous laxity** and **pannus-related bone erosion** at the atlantoaxial joint.

Q: A young man presents with chronic lower back pain and morning stiffness and pain on bending that improves with activity. X ray of LS spine is normal. Ocular examination shows anterior uveitis. Which diagnostic modality will pick up the disease process at the earliest?

MRI of the sacroiliac joints. ***MRI of the sacroiliac joints*** - **MRI** is the most sensitive and specific tool for detecting early inflammatory changes in the **sacroiliic joints** (sacroiliitis), such as bone marrow edema (osteitis) [1]. - It is crucial when plain radiography is normal, as it detects inflammatory lesions years before structural bony changes become visible on X-ray or CT scan, facilitating early diagnosis of **Ankylosing Spondylitis**. *Anti CCP antibody* - The **Anti-Cyclic Citrullinated Peptide (Anti-CCP)** antibody is highly specific for **Rheumatoid Arthritis (RA)**, which presents differently, typically affecting small peripheral joints [2]. - The clinical presentation of chronic back pain, morning stiffness improving with activity, and anterior uveitis is classic for **Spondyloarthritis** (like Ankylosing Spondylitis), not RA [3]. *CT scan of the sacroiliac joints* - **CT scan** is excellent for visualizing bony erosions, sclerosis, and joint fusion, which are **late structural changes** in sacroiliitis. - However, it is less sensitive than MRI in detecting the **early, active inflammatory phase** (bone marrow edema) that occurs before joint damage is established. *Bone scan* - A **Bone scan** (Technetium-99m) is sensitive but **not site-specific**; it shows increased tracer uptake in inflamed areas but cannot distinguish between degenerative, traumatic, or inflammatory causes [2]. - Its use in diagnosing sacroiliitis is largely superseded by **MRI** due to the latter's superior spatial resolution and ability to depict active inflammation directly.

Q: A 20-year-old man presents with chronic back pain that is worse in the morning and improves with physical activity. He also has a history of anterior uveitis. A lumbar spine X-ray shows no abnormalities. Which of the following is the most appropriate next investigation for early diagnosis?

MRI sacroiliac joints. The presentation (inflammatory back pain improving with activity, and anterior uveitis) strongly suggests **Ankylosing Spondylitis (AS)** [1]. MRI is the **most sensitive imaging modality** for early diagnosis, as it can detect acute, reversible inflammatory changes (like **bone marrow edema**) in the sacroiliac joints before they are visible on X-ray [1]. CT is superior for visualizing **bony changes** like erosions or fusion but is significantly less sensitive than MRI for detecting active **bone marrow inflammation** in the early stages of sacroiliitis [1]. X-ray of the spine is usually performed after SI joint films but will often be **normal in early disease** (as suggested by the clinical case, where lumbar X-ray was negative) [1]. Radiographic changes like squaring of vertebrae or **syndesmophytes** only appear much later in the disease course, making it inadequate for *early* diagnosis [1]. Bone scintigraphy (bone scan) is a **non-specific** test that shows increased uptake but has poor anatomical resolution for assessing the sacroiliac joint specifically [1].

Q: A 40-year-old man presents with discomfort in one of his joints. Synovial fluid aspiration reveals rhomboid-shaped, positively birefringent crystals under polarized light microscopy. Which of the following is the most likely diagnosis?

C. Pseudogout. ### Pseudogout - Pseudogout, or **Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition disease**, is classically identified by the presence of **rhomboid-shaped** crystals [1]. - These CPPD crystals exhibit **positive birefringence** under polarized light microscopy, a distinguishing feature from gout [1]. *Gout* - Gout is characterized by monosodium urate (MSU) crystals, which are **needle-shaped**, not rhomboid [1]. - MSU crystals show **strong negative birefringence**, appearing yellow when aligned parallel to the compensator axis (Yellow parallel) [1]. *Rheumatoid arthritis* - The primary diagnostic finding in rheumatoid arthritis (RA) synovial fluid is **inflammatory changes** (high WBC count, mostly neutrophils) and not the presence of crystals. - RA is associated with **RF** and **anti-CCP antibodies** and primarily affects smaller joints symmetrically. *Osteoarthritis* - Osteoarthritis (OA) synovial fluid is typically **non-inflammatory**, appearing viscous with a low white blood cell count (<2000 cells/mm³). - OA is a degenerative joint disease defined by **cartilage loss** and **osteophyte formation**, not crystal deposition [1].

Question 1

A 35-year-old patient presents with colicky abdominal pain, joint pain, and palpable purpura. Urinalysis shows only red blood cells with no other significant findings. Which of the following is the likely diagnosis?

Accepted Answer

IgA vasculitis

Answer

Behçet's disease

Answer

Granulomatosis with polyangiitis

Answer

Microscopic polyangiitis

Question 2

A 17-year-old woman with no comorbidities presents with numbness and paraesthesia of the fingers along with the characteristic finding as shown in the image below. She has no history of smoking or history of other illnesses. She mentions the episodes occur when she is under excess stress or during cold temperatures. What is the most likely diagnosis?

Accepted Answer

a. Raynaud's phenomenon

Answer

b. Buerger's disease

Answer

c. Atherosclerosis

Answer

d. Peripheral arterial disease

Question 3

A 50-year-old woman presented with difficulty in activities like climbing stairs, getting up from a chair, and combing hair. Violaceous erythema of the upper eyelids was noted. What is the most probable diagnosis?

Accepted Answer

Dermatomyositis

Answer

Inclusion body myositis

Answer

Polymyositis

Answer

Scleroderma

Question 4

A 50-year-old female patient with a known case of ovarian cancer presents with difficulty in activities like climbing stairs, getting up from a chair, combing hair, etc. The following characteristic sign was found on examination. The most probable diagnosis is:

Accepted Answer

Dermatomyositis

Answer

Systemic lupus erythematosus

Answer

Systemic sclerosis

Answer

Cushing syndrome

Question 5

An elderly patient with the following deformity was brought to the OPD. What is the most probable diagnosis? ![img-13.jpeg](img-13.jpeg)

Accepted Answer

Rheumatoid arthritis

Answer

Rickets

Answer

Osteomalacia

Answer

Osteoarthritis

Question 6

A 35-year-old female presents with symmetrical joint pain and morning stiffness lasting 2 hours involving small joints of hands for 6 months. Examination reveals swelling of metacarpophalangeal and proximal interphalangeal joints bilaterally. ESR is 55 mm/hr, CRP is elevated, and rheumatoid factor is positive. X-ray shows periarticular osteopenia. What is the most appropriate initial treatment?

Accepted Answer

Methotrexate with folic acid supplementation

Answer

NSAIDs alone for symptom control

Answer

Systemic corticosteroids only

Answer

Tumor necrosis factor inhibitors

Question 7

A patient with rheumatoid arthritis presents with neck pain and clinical signs of myelopathy. What is the most likely diagnosis?

Accepted Answer

Atlantoaxial dislocation

Answer

Osteoarthritis of vertebrae

Answer

Disc herniation

Answer

C2-C3 intervertebral stenosis

Question 8

A young man presents with chronic lower back pain and morning stiffness and pain on bending that improves with activity. X ray of LS spine is normal. Ocular examination shows anterior uveitis. Which diagnostic modality will pick up the disease process at the earliest?

Accepted Answer

MRI of the sacroiliac joints

Answer

CT scan of the sacroiliac joints

Answer

Bone scan

Answer

Anti CCP antibody

Question 9

A 20-year-old man presents with chronic back pain that is worse in the morning and improves with physical activity. He also has a history of anterior uveitis. A lumbar spine X-ray shows no abnormalities. Which of the following is the most appropriate next investigation for early diagnosis?

Accepted Answer

MRI sacroiliac joints

Answer

X-ray thoracolumbar spine

Answer

Bone scan

Answer

CT spine

Question 10

A 40-year-old man presents with discomfort in one of his joints. Synovial fluid aspiration reveals rhomboid-shaped, positively birefringent crystals under polarized light microscopy. Which of the following is the most likely diagnosis?

Accepted Answer

C. Pseudogout

Answer

A. Gout

Answer

B. Rheumatoid arthritis

Answer

D. Osteoarthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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