Rheumatology and Immunology Practice Questions

Q: A 35-year-old crane operator at construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. Chest X-ray was performed. What is the diagnosis?

Caplan syndrome. ***Caplan syndrome*** - The combination of **seropositive rheumatoid arthritis**, occupational exposure in a **coal mine** (crane operator at a construction site implies exposure to dust/silica), and the presence of **pulmonary nodules** on chest X-ray are classic features of Caplan syndrome. - This syndrome is a pneumoconiosis characterized by the development of distinctive, often large, well-defined **rheumatoid nodules** in the lungs of individuals with RA and simultaneous exposure to industrial dusts like coal or silica. *Felty syndrome* - Felty syndrome is a rare, severe complication of rheumatoid arthritis characterized by the triad of **rheumatoid arthritis**, **splenomegaly**, and **neutropenia**. - While it occurs in individuals with seropositive RA, it does not directly involve primary pulmonary consolidation or nodules as the main presenting feature. *Bronchiolitis obliterans organizing pneumonia* - This is a form of lung disease characterized by inflammation of the small airways and surrounding alveolar spaces, often presenting with **cough**, **dyspnea**, and **flu-like symptoms**. - Radiographically, it typically shows **patchy alveolar opacities** or **consolidation**, which is different from the distinct nodules seen in the image and characteristic of Caplan syndrome. *Lung cancer* - While lung cancer can manifest as a **pulmonary nodule** and cause dyspnea, the patient's history of **seropositive rheumatoid arthritis** and occupational exposure to dust strongly points towards an inflammatory-rheumatic etiology rather than primary malignancy. - The context of a pre-existing systemic autoimmune disease and specific occupational exposure makes **Caplan syndrome** a more specific and likely diagnosis given the radiologic findings.

Q: A 55-year-old female on methotrexate presents with continuous pain and swelling of bilateral hand joints. What is the best treatment plan for this patient?

Methotrexate + Sulphasalazine + Hydroxychloroquine. ***Methotrexate + Sulphasalazine + Hydroxychloroquine*** - This combination, known as **triple therapy**, is a well-established and effective strategy for **rheumatoid arthritis** patients who have an inadequate response to methotrexate monotherapy. - The combination of **conventional synthetic DMARDs (csDMARDs)** targets different inflammatory pathways, leading to a synergistic effect and improved disease control. *Double the dose of methotrexate* - While methotrexate doses can be optimized, simply doubling the dose may not be the most effective next step for uncontrolled disease and could increase the risk of **toxicity** without significantly improving efficacy. - Current guidelines often advocate for adding another DMARD or switching to a biologic agent if maximum tolerated methotrexate is insufficient. *Methotrexate + high potency Oral steroids* - Oral steroids are primarily used for **short-term symptom control** during flares or as a bridge therapy, not as a long-term strategy for sustained disease modification due to their significant side effect profile. - Adding high-potency oral steroids long-term with methotrexate would increase the risk of adverse effects like osteoporosis, infections, and adrenal insufficiency. *Stop methotrexate and start Monotherapy with anti-TNF- drugs* - While **anti-TNF drugs** are a powerful next-line treatment, **monotherapy** is generally less effective than combination therapy, especially for patients with active disease. - **Methotrexate is often continued** in combination with anti-TNF drugs even when initiating biological therapies, as it can enhance their efficacy and reduce immunogenicity.

Q: A patient presents with neck pain and rigidity which gets relieved after bathing in hot water and exercise. Cervical X-ray is shown below. What is your diagnosis?

Spondylitis. ***Spondylitis (Ankylosing Spondylitis)*** - The image shows **fusion of vertebral bodies** (ankylosis) and an appearance consistent with a **bamboo spine**, which is characteristic of advanced **Ankylosing Spondylitis**. - The clinical presentation is pathognomonic: **inflammatory back pain with morning stiffness** that is **relieved by activity and hot water bathing** (as opposed to mechanical pain which worsens with activity). - This is a classic presentation of inflammatory spondyloarthropathy, specifically ankylosing spondylitis. *Spondylolisthesis* - This condition involves the **slippage of one vertebra over another**, which is not the primary finding on this X-ray. - While spondylolisthesis can cause neck pain, it does **not typically present with diffuse vertebral fusion** as seen here, and the pain would worsen with activity (mechanical pattern), not improve. *Spondylosis* - Spondylosis refers to **degenerative changes** of the spine, often involving **osteophytes** and **disc space narrowing**. - While some degenerative changes may be present, the pronounced fusion and **"bamboo spine" appearance** go beyond typical spondylosis and indicate an inflammatory process. - Degenerative pain typically **worsens with activity**, unlike the relief with exercise seen in this patient. *Spondyloptosis* - Spondyloptosis is an **extreme form of spondylolisthesis** where one vertebra has completely slipped off the one below it (Grade V slip). - This severe displacement is not apparent on the X-ray; instead, there is **fusion rather than translational instability**.

Q: A 25-year-old lady presents with inability to form a fist and marked stiffening of joints. Diagnosis is:

Scleroderma. ***Scleroderma*** - The combination of **inability to form a fist** (due to hardening and tightening of the skin on the hands) and marked **stiffening of joints** (often affecting multiple joints) is characteristic of systemic sclerosis, commonly known as scleroderma. - Scleroderma causes **fibrosis** of the skin and internal organs, leading to skin thickening, **Raynaud's phenomenon**, and potential involvement of the lungs, heart, kidneys, and gastrointestinal tract. *Coup de sabre* - This is a localized form of morphea (linear scleroderma) occurring on the face or scalp. It presents as a **linear atrophy** and pigmentation, resembling a saber-cut. - While it involves skin hardening, it typically does not cause generalized joint stiffening or diffuse inability to form a fist that suggests widespread systemic involvement. *Morphea* - **Morphea** is a localized form of scleroderma that primarily affects the skin, causing well-demarcated patches of hardened, discolored skin. - Unlike systemic scleroderma, morphea **rarely involves internal organs** or causes generalized joint stiffness to the extent described in the clinical vignette. *Rheumatoid arthritis* - Rheumatoid arthritis is a chronic inflammatory joint disease primarily affecting the **synovial membranes** of multiple joints, typically presenting with **morning stiffness** lasting over 30 minutes, swelling, and tenderness. - While it can cause joint stiffness and hand deformities, the clinical picture would usually include significant **joint inflammation** (redness, swelling) and would not typically manifest as the diffuse skin hardening that leads to an "inability to form a fist" due to skin tightness, as seen in scleroderma.

Q: The best drug for maintenance therapy of Systemic Lupus Erythematosus (SLE) during pregnancy is :

Hydroxychloroquine. ***Hydroxychloroquine*** - **Hydroxychloroquine** is the cornerstone of SLE treatment, including during pregnancy, due to its efficacy in preventing flares and its established safety profile for both mother and fetus. - Continuation of **hydroxychloroquine** throughout pregnancy is recommended to reduce the risk of disease activity, which can lead to adverse maternal and fetal outcomes. *Tacrolimus* - **Tacrolimus** is an immunosuppressant typically reserved for patients with severe organ-threatening lupus, such as lupus nephritis, especially when other treatments fail or are contraindicated. - While it can be used in pregnancy under close monitoring, it is not considered the first-line or best drug for routine maintenance therapy due to potential risks and the availability of generally safer options. *Progestins* - **Progestins** are hormones primarily used in contraception or hormone replacement therapy and have no direct role in the treatment or maintenance of systemic lupus erythematosus. - They do not possess immunomodulatory properties essential for managing SLE disease activity. *Sulfasalazine* - **Sulfasalazine** is an anti-inflammatory and immunomodulatory drug primarily used for inflammatory bowel disease and rheumatoid arthritis, and sometimes for psoriatic arthritis. - It is not a standard treatment for **Systemic Lupus Erythematosus (SLE)** and is less effective for systemic manifestations of lupus.

Q: Treatment of first choice in acute Gout is

Oral Colchicine. ***Oral Colchicine*** - **Colchicine** is highly effective in treating **acute gout attacks** by reducing inflammation caused by uric acid crystal deposition. - It works best when initiated within **24-36 hours** of symptom onset. - Considered a **first-line option** for acute gout, particularly in patients with contraindications to NSAIDs or corticosteroids. - **Mechanism:** Inhibits microtubule polymerization, thereby reducing neutrophil migration and phagocytosis of urate crystals. *Oral Methotrexate* - **Methotrexate** is an **immunosuppressant** primarily used for chronic inflammatory conditions, such as **rheumatoid arthritis** or **psoriasis**. - It is not a first-line treatment for the rapid relief of acute gout symptoms. *Sulfasalazine* - **Sulfasalazine** is an anti-inflammatory and immunomodulatory drug, commonly used in **inflammatory bowel disease** and **rheumatoid arthritis**. - It has no role in the immediate treatment of an acute gout flare. *Allopurinol* - **Allopurinol** is a **xanthine oxidase inhibitor** used for the **long-term prevention** of gout by lowering uric acid levels. - It is generally *not initiated* during an acute attack, as it can potentially worsen the flare by mobilizing urate crystals. - Used for **prophylaxis** in patients with recurrent gout attacks or chronic tophaceous gout.

Q: Which one of the following terms denotes the extensive sclerosis of the skin of the chest wall which restricts chest wall movement and is seen as a rare complication of systemic sclerosis?

Hidebound Chest. ***Hidebound Chest*** - This term precisely describes the **extensive cutaneous sclerosis** over the chest wall seen in **systemic sclerosis**, leading to restricted chest movement [1]. - The hardened, thickened skin reduces chest wall compliance, making breathing difficult [1]. *Barrel Chest* - Characterized by an **increased anterior-posterior diameter** of the chest, commonly seen in chronic obstructive pulmonary disease (COPD) due to hyperinflation. - It is not primarily caused by skin sclerosis but rather by lung pathology. *Flail Chest* - Occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. - This results in **paradoxical movement** of the chest wall during respiration, and is an acute traumatic injury. *Pigeon Chest* - Also known as **Pectus Carinatum**, this chest wall deformity is characterized by a **protrusion of the sternum and costal cartilages**. - It is typically a developmental anomaly rather than a consequence of skin sclerosis.

Q: A 40-year-old lady complains of progressive deformities of her hands and fingers associated with stiffness which is present in both the hands and improves as the day progresses. On examination, there is symmetrical involvement of hands and fingers of both the upper limbs with flexion and ulnar deviation at the metacarpophalangeal joints. What is the most likely diagnosis in this lady?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - The combination of **symmetrical polyarthritis** affecting the hands and fingers, **morning stiffness** that improves with activity ("improves as the day progresses" not as severe as morning stiffness) [1][4], and characteristic **flexion and ulnar deviation at the metacarpophalangeal joints** (Swan-neck, Boutonniere's, and Z-thumb deformities) are classic features of rheumatoid arthritis (RA) [3]. - RA is an **autoimmune disease** causing chronic inflammation of the synovial lining of joints, leading to progressive joint damage and characteristic deformities [3]. *Ankylosing spondylitis* - This condition primarily affects the **axial skeleton** (spine and sacroiliac joints), causing **back pain and stiffness**, not typically significant small joint deformities of the hands. - While it can involve peripheral joints, it is often **asymmetrical** and doesn't present with the specific hand deformities described. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease characterized by **cartilage breakdown**, leading to pain that **worsens with activity** and improves with rest [2]. - Joint involvement is often **asymmetrical** and typically affects weight-bearing joints or causes **Heberden's** and **Bouchard's nodes** in the fingers, not the symmetrical MCP involvement and specific deformities seen here [2]. *Tenosynovitis* - **Tenosynovitis** is an inflammation of the **synovial sheath surrounding a tendon**, causing localized pain, swelling, and difficulty moving the affected digit or limb. - It does not explain the widespread, symmetrical joint involvement, progressive deformities of multiple joints, or systemic nature of the symptoms described.

Q: Which of the following are correct about Felty's syndrome? 1. It is associated with rheumatoid arthritis. 2. It may present with leukopenia. 3. It may have splenomegaly. 4. Splenectomy always improves the blood picture.

1, 2 and 3. ***1, 2 and 3*** - Felty's syndrome is a severe variant of **rheumatoid arthritis** characterized by the triad of **rheumatoid arthritis**, **splenomegaly**, and **neutropenia** (a type of leukopenia) [1]. - While splenectomy can be considered for persistent severe neutropenia, it does not **always improve the blood picture** and is reserved for cases unresponsive to other treatments. *1, 2 and 4* - This option correctly identifies the association with **rheumatoid arthritis** and **leukopenia** but incorrectly states that splenectomy **always improves the blood picture**. - Splenectomy is not a guarantee of improvement and is considered a last resort. *1, 3 and 4* - This option correctly identifies the association with **rheumatoid arthritis** and **splenomegaly** but incorrectly concludes that splenectomy **always improves the blood picture**, and misses the characteristic **leukopenia**. - Leukopenia, specifically neutropenia, is a defining feature of Felty's syndrome [1]. *2, 3 and 4* - This option incorrectly states that Felty's syndrome is always associated with leukopenia and splenomegaly, but the crucial missing element is its clear association with **rheumatoid arthritis**. - The primary underlying condition for Felty's syndrome is **long-standing, severe rheumatoid arthritis** [1].

Question 1

A 35-year-old crane operator at construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. Chest X-ray was performed. What is the diagnosis?

Accepted Answer

Caplan syndrome

Answer

Felty syndrome

Answer

Bronchiolitis obliterans organizing pneumonia

Answer

Lung cancer

Question 2

A 55-year-old female on methotrexate presents with continuous pain and swelling of bilateral hand joints. What is the best treatment plan for this patient?

Accepted Answer

Methotrexate + Sulphasalazine + Hydroxychloroquine

Answer

Double the dose of methotrexate

Answer

Methotrexate + high potency Oral steroids

Answer

Stop methotrexate and start Monotherapy with anti-TNF- drugs

Question 3

A patient presents with neck pain and rigidity which gets relieved after bathing in hot water and exercise. Cervical X-ray is shown below. What is your diagnosis?

Accepted Answer

Spondylitis

Answer

Spondylolisthesis

Answer

Spondylosis

Answer

Spondyloptosis

Question 4

A 25-year-old lady presents with inability to form a fist and marked stiffening of joints. Diagnosis is:

Accepted Answer

Scleroderma

Answer

Coup de sabre

Answer

Morphea

Answer

Rheumatoid arthritis

Question 5

The best drug for maintenance therapy of Systemic Lupus Erythematosus (SLE) during pregnancy is :

Accepted Answer

Hydroxychloroquine

Answer

Tacrolimus

Answer

Progestins

Answer

Sulfasalazine

Question 6

Treatment of first choice in acute Gout is

Accepted Answer

Oral Colchicine

Answer

Oral Methotrexate

Answer

Sulfasalazine

Answer

Allopurinol

Question 7

Which one of the following terms denotes the extensive sclerosis of the skin of the chest wall which restricts chest wall movement and is seen as a rare complication of systemic sclerosis?

Accepted Answer

Hidebound Chest

Answer

Barrel Chest

Answer

Flail Chest

Answer

Pigeon Chest

Question 8

Which one of the following statements is correct in respect of pulmonary involvement in rheumatoid disease?

Accepted Answer

Rheumatoid pulmonary nodules are usually asymptomatic and detected incidentally on imaging

Answer

Pleural effusion in these patients is transudative and usually bilateral

Answer

Rheumatoid pulmonary nodules are often solitary and located near hilum

Answer

Combination of pleural effusion and pneumoconiosis in these patients is known as Caplan syndrome

Question 9

A 40-year-old lady complains of progressive deformities of her hands and fingers associated with stiffness which is present in both the hands and improves as the day progresses. On examination, there is symmetrical involvement of hands and fingers of both the upper limbs with flexion and ulnar deviation at the metacarpophalangeal joints. What is the most likely diagnosis in this lady?

Accepted Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Osteoarthritis

Answer

Tenosynovitis

Question 10

Which of the following are correct about Felty's syndrome?

1. It is associated with rheumatoid arthritis.
2. It may present with leukopenia.
3. It may have splenomegaly.
4. Splenectomy always improves the blood picture.

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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