Rheumatology and Immunology Practice Questions

Q: History of a woman with skin features like limited cutaneous systemic sclerosis (scleroderma) was given. What is the most specific marker?

Anti centromere. ***Anti centromere*** - **Anti-centromere antibodies** are highly specific for **limited cutaneous systemic sclerosis** (lcSSc), also known as CREST syndrome. - Their presence correlates with a higher risk of **pulmonary hypertension** and less severe organ involvement compared to diffuse SSc [1]. *Anti U1 Rnp* - **Anti-U1 RNP antibodies** are primarily associated with **mixed connective tissue disease** (MCTD) [2]. - While MCTD can have features overlapping with scleroderma, anti-U1 RNP is not the most specific marker for a pure scleroderma presentation. *Anti Jo* - **Anti-Jo-1 antibodies** are characteristic of **polymyositis** and **dermatomyositis**, diseases involving muscle inflammation [2]. - They are primarily associated with the **anti-synthetase syndrome**, which includes myositis, interstitial lung disease, and Raynaud's phenomenon, not directly limited cutaneous systemic sclerosis. *Anti La* - **Anti-La (SS-B) antibodies** are commonly found in patients with **Sjögren's syndrome**, an autoimmune disorder affecting moisture-producing glands [2]. - They can also be present in systemic lupus erythematosus, but are not specific for scleroderma.

Q: A 48-year-old female presents to your office with a 1-year history of dry eyes and difficulty swallowing. She complains of blinking frequently and of eye strain while using her computer at work. She also reports stiffness in her knees and lower back. Past medical history is unremarkable and she does not take medications. She denies cigarette or alcohol use. Family history is notable for Hashimoto's thyroiditis in her mother. Physical exam shows dry oral mucosa and enlargement of the parotid glands. Which of the following serologies is likely to be positive in this patient?

Anti-SS-A. ***Anti-SS-A*** * This patient's symptoms of **dry eyes**, **difficulty swallowing**, **dry oral mucosa**, and **enlarged parotid glands** are highly indicative of **Sjögren's syndrome** [1]. * **Anti-SS-A (Ro)** antibodies are present in 60-70% of patients with primary Sjögren's syndrome and are recognized as a diagnostic marker [1]. * *Anti-Jo-1* * **Anti-Jo-1** antibodies are primarily associated with **polymyositis** and **dermatomyositis**, particularly the anti-synthetase syndrome, characterized by muscle weakness and interstitial lung disease, which are not described in this patient. * The patient's symptoms are focused on sicca manifestations rather than muscle inflammation. * *Anti-dsDNA* * **Anti-dsDNA** antibodies are highly specific for **Systemic Lupus Erythematosus (SLE)** and are often associated with lupus nephritis. * The patient presents with symptoms more consistent with a primary sicca disorder rather than the multi-systemic involvement typical of SLE. * *Anti-Smith* * **Anti-Smith** antibodies are also highly specific for **Systemic Lupus Erythematosus (SLE)**, though less sensitive than anti-dsDNA [1]. * These antibodies are not typically found in Sjögren's syndrome without co-existing SLE. * *Anti-CCP* * **Anti-CCP (cyclic citrullinated peptide)** antibodies are highly specific for **rheumatoid arthritis** [2]. * While the patient reports knee and lower back stiffness, the primary complaints and physical findings point towards Sjögren's syndrome, not inflammatory arthritis.

Q: A lady, when exposed to cold, experiences extremities turning blue. Which of the following antibodies is associated with this condition?

Anti-SCL-70. Anti-SCL-70 - The symptom of extremities turning blue, especially upon cold exposure, describes **Raynaud's phenomenon**, a common feature of **systemic sclerosis (scleroderma)** [1]. - **Anti-SCL-70 antibodies** (topoisomerase 1 antibodies) are highly specific for **diffuse cutaneous systemic sclerosis**, a severe form of the disease often associated with Raynaud's. *Anti-RO* - **Anti-RO (SSA) antibodies** are primarily associated with **Sjögren's syndrome** and **subacute cutaneous lupus erythematosus**, conditions not typically characterized by prominent Raynaud's as the presenting symptom [2]. - While Sjögren's syndrome can have Raynaud's, it's not the defining feature and other symptoms like **dry eyes** and **dry mouth** would likely be present. *Anti-SS-B* - **Anti-SS-B (La) antibodies** are also associated with **Sjögren's syndrome**, often appearing alongside anti-RO antibodies [2]. - Their presence does not directly point to diffuse systemic sclerosis or severe Raynaud's as the primary condition. *Anti-SS-A* - **Anti-SS-A (RO) antibodies** are primarily linked to **Sjögren's syndrome** and **neonatal lupus**, and can also be seen in **systemic lupus erythematosus** [2]. - While Raynaud's can occur in lupus, the presence of isolated cold-induced blue extremities points more strongly towards systemic sclerosis given the provided options.

Q: Which of the following is the best investigation for acute gout?

Uric acid in synovial fluid. ***Uric acid in synovial fluid*** - The definitive diagnosis of acute gout is established by identifying **negatively birefringent needle-shaped uric acid crystals** within the synovial fluid of the affected joint [1]. - This method directly confirms the presence of **monosodium urate crystals**, which are the hallmark of gout, offering diagnostic certainty [1]. *Uric acid in urine* - While urinary uric acid levels can help assess uric acid excretion, they are not diagnostic for acute gout and do not directly show the presence of **intra-articular crystals**. - This test is more relevant for investigating the **cause of hyperuricemia** (overproduction vs. underexcretion) rather than diagnosing an acute flare. *Anti CCP antibodies* - **Anti-cyclic citrullinated peptide (anti-CCP) antibodies** are markers for **rheumatoid arthritis** and are not relevant for the diagnosis of acute gout. - Their presence indicates an autoimmune inflammatory condition distinct from crystal-induced arthropathy. *Serum uric acid* - Serum uric acid levels are often elevated during an acute gout flare (**hyperuricemia**), but this is not diagnostic, as many individuals with hyperuricemia never develop gout [1]. - Approximately 30% of patients may have **normal serum uric acid levels** during an acute attack, making it an unreliable sole diagnostic criterion.

Q: Diagnosis of Gout is confirmed by which test?

Synovial fluid analysis. ***Synovial fluid analysis*** - Diagnosis of gout is definitively confirmed by the presence of **negatively birefringent, needle-shaped urate crystals** within neutrophils in the synovial fluid [1]. - This direct visualization of crystals confirms the diagnosis and differentiates gout from other forms of arthritis [1]. *X-ray changes* - While X-rays can show characteristic changes in chronic gout, such as **punched-out erosions with overhanging edges** (rat-bite erosions), these are not diagnostic of acute gout and may appear late in the disease course. - X-ray findings are less specific and do not confirm the presence of urate crystals. *Urine uric acid levels* - Urine uric acid levels help to distinguish between **overproducers and underexcreters** of uric acid, which can guide long-term management strategies [1]. - However, they do not directly confirm the diagnosis of an acute gouty attack. *Serum Uric acid level* - Elevated serum uric acid (hyperuricemia) is a prerequisite for gout, but many individuals with hyperuricemia never develop gout [1]. - Therefore, a **high serum uric acid level alone is not sufficient** to diagnose gout, especially during an acute attack when levels can sometimes be normal [1].

Q: Primary osteoarthritis affects all except:

Metacarpophalangeal joint. ***Metacarpophalangeal joint*** - The **metacarpophalangeal (MCP) joints** are typically spared in primary osteoarthritis, making their involvement a less common presentation. - Involvement of the MCP joints, particularly with significant inflammation, might suggest other conditions like **rheumatoid arthritis**. *Hip Joint* - The hip joint is a common site for primary osteoarthritis due to its **weight-bearing function** and susceptibility to mechanical stress. - Patients often experience **groin pain** and reduced range of motion, particularly internal rotation. *Distal interphalangeal joint* - The **distal interphalangeal (DIP) joints** are very commonly affected in primary osteoarthritis, leading to the formation of **Heberden's nodes**. - These nodes are bony enlargements that indicate osteophyte formation and cartilage loss. *Knee joint* - The knee joint is another frequently affected large joint in primary osteoarthritis, often presenting with **pain**, **stiffness**, and **crepitus**. - Its **weight-bearing role** contributes significantly to its vulnerability to degenerative changes.

Q: A 52-year-old woman has long-standing rheumatoid arthritis (RA) and is being treated with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following cardiac complications may arise in this clinical setting?

Constrictive pericarditis. ***Constrictive pericarditis*** - Chronic **inflammation** associated with rheumatoid arthritis can lead to pericardial involvement, often manifesting as **pericardial effusion** or **fibrosis**. [1] - Over time, this fibrosis can progress to **pericardial thickening** and calcification, impairing diastolic filling and causing symptoms of constrictive pericarditis. [1] *Hypertrophic cardiomyopathy* - This condition is characterized by **left ventricular hypertrophy** without an identifiable cause like hypertension or aortic stenosis. - It is primarily a **genetic disorder** of the sarcomere and is not typically associated with rheumatoid arthritis or its treatments. [2] *Restrictive cardiomyopathy* - Characterized by stiff, non-compliant ventricular walls that restrict diastolic filling, often due to **infiltrative diseases** like amyloidosis or sarcoidosis. [2] - While RA can cause amyloidosis, it is not the most direct or common cardiac complication, and this diagnosis focuses on myocardial stiffness rather than pericardial disease. [3, 4] *Dilated cardiomyopathy* - Involves **enlargement and weakening** of the heart ventricles, leading to impaired systolic function. - It can be caused by various factors including viral infections, alcohol, or genetic predisposition, but is not a typical direct cardiac complication of rheumatoid arthritis. [2]

Q: Arthritis mutilans is seen in?

Psoriatic arthropathy. ***Psoriatic arthropathy*** - **Arthritis mutilans** is a severe, destructive form of arthritis characterized by the **resorption of bone**, leading to **telescoping of digits** and severe deformities, most commonly seen in psoriatic arthritis [1]. - It affects approximately 5% of patients with psoriatic arthritis and is associated with significant functional impairment [1]. *Reactive arthritis* - Characterized by **asymmetric oligoarthritis** that typically follows a **genitourinary or gastrointestinal infection** [2]. - While it can cause joint inflammation, it is not associated with the severe bone resorption and telescoping deformities seen in arthritis mutilans [2]. *Rheumatoid arthritis* - Primarily affects the **small joints** of the hands and feet symmetrically, leading to inflammation, pannus formation, and joint destruction, but typically not **bone resorption** leading to telescoping [3]. - While significant joint deformities can occur (e.g., **swan-neck**, **boutonnière deformities**), these are distinct from the *pencil-in-cup* or telescoping appearance of arthritis mutilans [3]. *Spondyloarthropathy* - This is a broader category of inflammatory arthritides including **ankylosing spondylitis**, psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis [4]. - While **psoriatic arthropathy** is a type of spondyloarthropathy, the term itself is too general to specifically indicate arthritis mutilans.

Question 1

History of a woman with skin features like limited cutaneous systemic sclerosis (scleroderma) was given. What is the most specific marker?

Accepted Answer

Anti centromere

Answer

Anti U1 Rnp

Answer

Anti Jo

Answer

Anti La

Question 2

A 35-year-old woman presents with multiple painless nodules on her shins, forearms, and around her eyes. Biopsy shows non-caseating granulomas. Chest X-ray reveals bilateral hilar lymphadenopathy. Which of the following is most likely to be elevated in this condition?

Accepted Answer

Angiotensin-converting enzyme

Answer

C-ANCA

Answer

Anti-centromere antibodies

Answer

Rheumatoid factor

Answer

Anti-histone antibodies

Question 3

A 48-year-old female presents to your office with a 1-year history of dry eyes and difficulty swallowing. She complains of blinking frequently and of eye strain while using her computer at work. She also reports stiffness in her knees and lower back. Past medical history is unremarkable and she does not take medications. She denies cigarette or alcohol use. Family history is notable for Hashimoto's thyroiditis in her mother. Physical exam shows dry oral mucosa and enlargement of the parotid glands. Which of the following serologies is likely to be positive in this patient?

Accepted Answer

Anti-SS-A

Answer

Anti-Jo-1

Answer

Anti-dsDNA

Answer

Anti-Smith

Answer

Anti-CCP

Question 4

A lady, when exposed to cold, experiences extremities turning blue. Which of the following antibodies is associated with this condition?

Accepted Answer

Anti-SCL-70

Answer

Anti-RO

Answer

Anti-SS-B

Answer

Anti-SS-A

Question 5

Which of the following is the best investigation for acute gout?

Accepted Answer

Uric acid in synovial fluid

Answer

Uric acid in urine

Answer

Anti CCP antibodies

Answer

Serum uric acid

Question 6

Diagnosis of Gout is confirmed by which test?

Accepted Answer

Synovial fluid analysis

Answer

X- ray changes

Answer

Urine uric acid levels

Answer

Serum Uric acid level

Question 7

Primary osteoarthritis affects all except:

Accepted Answer

Metacarpophalangeal joint

Answer

Hip Joint

Answer

Distal interphalangeal joint

Answer

Knee joint

Question 8

A 52-year-old woman has long-standing rheumatoid arthritis (RA) and is being treated with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following cardiac complications may arise in this clinical setting?

Accepted Answer

Constrictive pericarditis

Answer

Hypertrophic cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Dilated cardiomyopathy

Question 9

Arthritis mutilans is seen in?

Accepted Answer

Psoriatic arthropathy

Answer

Reactive arthritis

Answer

Rheumatoid arthritis

Answer

Spondyloarthropathy

Question 10

The primary goal of glucocorticoid treatment in rheumatoid arthritis is:

Accepted Answer

Suppression of inflammation and improvement in functional capacity

Answer

Prevention of suppression of the hypothalamic pituitary adrenal axis

Answer

Development of a sense of well-being in the patient

Answer

Reversal of the degenerative process

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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