Rheumatology and Immunology Practice Questions

Q: According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:

Atrophy of quadriceps muscles. ### Atrophy of quadriceps muscles - While muscle weakness can be a consequence of **osteoarthritis (OA)** due to pain and disuse, **quadriceps atrophy** is not a primary diagnostic criterion according to the American College of Rheumatology (ACR) criteria for OA. Local examination of the knee in OA may frequently reveal weakness and wasting of the quadriceps muscle [1]. - The ACR criteria primarily focus on patient symptoms, physical exam findings, and radiographic evidence to define OA. ### Lack of warmth - This is a typical physical finding in osteoarthritis, as **inflammation** is generally mild or absent compared to inflammatory arthropathies, thus joints are usually **not warm** to the touch. - It helps differentiate OA from conditions like septic arthritis or gout, where warmth is a prominent feature. ### Crepitus - **Crepitus**, or crackling/grating sounds during joint movement, is a classic clinical finding in osteoarthritis, indicating a roughened articular surface. Examination often reveals restricted flexion/extension accompanied by coarse crepitus [1]. - It is one of the key clinical signs used in the ACR criteria for OA, especially when combined with other symptoms like pain and stiffness. ### Age > 50 years - **Age over 50 years** is a significant risk factor and a clinical criterion for diagnosing osteoarthritis, as the prevalence of OA increases with age. While typical symptoms usually present after age 45-50, early-onset OA is rare and often linked to trauma [1]. - The ACR criteria often incorporate age as a factor when considering symptomatic OA.

Q: A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis is

Antinuclear antibody. ***Antinuclear antibody*** - The symptoms (Raynaud's phenomenon, arthralgias, dysphagia) are highly suggestive of a **systemic autoimmune disease**, such as **scleroderma** or **mixed connective tissue disease** [1], [2]. - An elevated **ANA** is a screening test for most autoimmune connective tissue diseases [1]; further specific autoantibodies (e.g., anti-centromere, anti-Scl-70) would then be ordered to confirm the specific diagnosis. *Rheumatoid factor* - While positive in **rheumatoid arthritis**, the patient's symptoms (Raynaud's, dysphagia) are less typical for RA and more indicative of other connective tissue disorders [1]. - A positive RF alone would not definitively diagnose the underlying systemic condition suggested by the symptom complex. *BUN and creatinine* - These tests assess **kidney function** and would be abnormal in cases of **renal involvement** due to autoimmune disease [1]. - While important for monitoring disease progression and complications, they are not a primary diagnostic test for the initial diagnosis of a systemic autoimmune condition. *ECG* - An **ECG** evaluates **cardiac electrical activity** and can detect arrhythmias or signs of ischemia. - While systemic autoimmune diseases can affect the heart, an ECG is not a screening or diagnostic test for the underlying autoimmune condition itself.

Q: A young girl is admitted with joint pains and butterfly rash and positive urine proteinuria. The best test for her diagnosis is ?

Anti ds-DNA antibody. ***Anti ds-DNA antibody*** - The presence of **joint pains**, a **butterfly rash** (malar rash), and **proteinuria** are classic clinical features highly suggestive of **Systemic Lupus Erythematosus (SLE)** [1]. - **Anti-dsDNA antibodies** are highly specific for SLE and correlate well with disease activity, especially **lupus nephritis**, which is indicated by proteinuria [4]. *Antibodies to RNP* - **Anti-RNP antibodies** are associated with **Mixed Connective Tissue Disease (MCTD)** and can be present in SLE, but they are not as specific for SLE or its renal involvement as anti-dsDNA [2]. - While MCTD can have overlapping features with SLE [3], the combination of a butterfly rash and significant proteinuria steers the diagnosis more directly towards SLE. *Antibodies to tRNA synthetase* - **Anti-tRNA synthetase antibodies** (e.g., anti-Jo-1) are characteristic of **inflammatory myopathies** such as polymyositis and dermatomyositis, not SLE. - These antibodies are typically associated with muscle weakness, interstitial lung disease, and "mechanic's hands," which are not described in the patient's presentation. *Anti-centromere antibody* - **Anti-centromere antibodies** are highly specific for **Limited Cutaneous Systemic Sclerosis (CREST syndrome)** [2]. - CREST syndrome presents with calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias, which are not mentioned in this patient's symptoms.

Q: False about Reactive arthritis

Acute purulent arthritis. ***Acute purulent arthritis*** - Reactive arthritis is a **sterile inflammatory arthritis**, meaning there is no bacterial infection in the joint fluid. - **Purulent arthritis** indicates a bacterial infection within the joint, which is not characteristic of reactive arthritis. *Enthesitis of Achilles tendon* - **Enthesitis**, particularly involving the Achilles tendon, is a common feature of **spondyloarthropathies**, including reactive arthritis [1]. - It refers to inflammation at the insertion sites of tendons, ligaments, or joint capsules into bone [1]. *Precipitated by chlamydia* - Reactive arthritis is frequently triggered by **genitourinary infections**, such as those caused by *Chlamydia trachomatis* [1]. - It falls under the category of **post-infectious arthritis**, where the infection precedes the joint symptoms [1]. *Indomethacin is the initial treatment of choice* - **Nonsteroidal anti-inflammatory drugs (NSAIDs)**, such as indomethacin, are the **first-line treatment** for managing pain and inflammation in reactive arthritis. - They help reduce joint pain, stiffness, and swelling, providing symptomatic relief.

Q: Most sensitive test for screening of SLE is

Anti-nuclear antibody. ***Anti-nuclear antibody*** - An **ANA test** is highly sensitive for **Systemic Lupus Erythematosus (SLE)**, meaning a negative result makes SLE highly unlikely [1]. - While not specific for SLE, a positive ANA serves as an excellent **screening tool** to prompt further, more specific testing. *Rheumatoid factor test* - This test is primarily used for **Rheumatoid Arthritis** and is not a sensitive or specific marker for SLE [1]. - While it can be positive in some SLE patients, its utility as a primary screening test for SLE is limited compared to ANA. *Double-stranded DNA test* - **Anti-dsDNA antibodies** are highly specific for SLE and often correlate with disease activity, especially **lupus nephritis**. - However, they are **not as sensitive as ANA** for initial screening, meaning some SLE patients might have a negative anti-dsDNA test but still have the disease. *LE cell phenomenon* - The **LE cell phenomenon** is an older, less sensitive, and less specific test for SLE that has largely been replaced by modern serologic tests. - Its detection involves observing neutrophils engulfing nuclear material, but it is **technically challenging** and prone to false negatives and positives.

Q: Anti ds DNA is most specific for:

SLE. ***SLE*** - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are often associated with **lupus nephritis** and disease activity [1]. - Their presence, along with clinical criteria, helps in confirming the diagnosis of SLE. *Polymyositis* - Polymyositis is characterized by **proximal muscle weakness** and elevated muscle enzymes, but not primarily by anti-dsDNA antibodies [1]. - Key autoantibodies in polymyositis include **anti-Jo-1** and other myositis-specific antibodies. *Scleroderma* - **Scleroderma (Systemic Sclerosis)** is characterized by skin thickening and internal organ fibrosis, with autoantibodies like **anti-Scl-70** and **anti-centromere antibodies** [1]. - **Anti-dsDNA antibodies** are not typically found in scleroderma. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** is a chronic inflammatory disorder primarily affecting the joints, and its characteristic autoantibodies are **rheumatoid factor (RF)** and **anti-citrullinated peptide antibodies (ACPA)**. - **Anti-dsDNA antibodies** are not relevant to the diagnosis of rheumatoid arthritis [1].

Q: All the following diseases are associated with HLA B-27 & Uveitis, except -

Behçet's syndrome. **Behçet's syndrome** - **Behçet's syndrome** is an immune-mediated vasculitis characterized by recurrent oral and genital ulcers, skin lesions, and **uveitis**. It is strongly associated with **HLA-B51**, not HLA-B27. - While it can cause uveitis, its genetic association and clinical presentation are distinct from the HLA-B27 spondyloarthropathies. *Ankylosing Spondylitis* - **Ankylosing Spondylitis** is a chronic inflammatory disease primarily affecting the axial skeleton, characterized by sacroiliitis and spondylitis. It is strongly associated with **HLA-B27** and can present with **anterior uveitis** [1]. - Approximately 25-40% of patients with ankylosing spondylitis experience acute anterior uveitis, making it a common extra-articular manifestation. *Psoriasis* - **Psoriasis** is a chronic inflammatory skin condition that can be associated with **psoriatic arthritis**, a spondyloarthropathy [1]. Psoriatic arthritis has a genetic predisposition, with some cases linked to **HLA-B27**, and can manifest with **uveitis**. - The presence of uveitis in a patient with psoriasis and joint pain suggests psoriatic arthritis, a disease known to be associated with HLA-B27 in a subset of patients. *Reiter's syndrome* - **Reiter's syndrome**, now more commonly referred to as **Reactive Arthritis**, is a seronegative spondyloarthropathy that typically develops after a genitourinary or gastrointestinal infection. It is strongly associated with **HLA-B27** [1]. - The classic triad of symptoms includes **arthritis**, **urethritis**, and **conjunctivitis** or **uveitis**, making it a clear association with both HLA-B27 and uveitis [2].

Q: Risk factors associated with development of Gout all except

Female sex. ***Female sex*** - While gout can affect women, especially post-menopause, **male sex** is a significant and consistent risk factor for gout development due to higher baseline uric acid levels. - Before menopause, **estrogen has a uricosuric effect**, helping to excrete uric acid and protecting against gout. *Thiazide* - **Thiazide diuretics** reduce the excretion of uric acid by the kidneys, leading to **hyperuricemia** and increasing the risk of gout flares [2]. - This medication-induced elevation of uric acid is a well-established risk factor for gout [2]. *High fructose intake* - **Fructose metabolism** increases the production of uric acid by promoting purine degradation while simultaneously reducing its renal excretion [1]. - This dual effect makes high fructose consumption, particularly from sugary drinks, a significant dietary risk factor for gout [1]. *Alcohol* - **Alcohol consumption**, especially beer and spirits, increases uric acid production and reduces its renal excretion, leading to **hyperuricemia** [3]. - This impact on uric acid metabolism makes alcohol a major dietary risk factor for the development of gout [3].

Q: Which of the following is commonly seen in SLE?

↑ed ANA. ***↑ed ANA*** - A positive **Antinuclear Antibody (ANA)** test is present in over 95% of patients with **Systemic Lupus Erythematosus (SLE)**, making it a highly sensitive screening test [1]. - While not specific to SLE, an elevated ANA is a cornerstone of its diagnostic criteria and indicates the presence of autoantibodies. *Autoimmune hemolytic anaemia* - While **autoimmune hemolytic anemia** can occur in SLE, it is not as universally common as an elevated ANA; it represents one of many potential hematologic manifestations [1]. - It results from autoantibodies targeting red blood cells, leading to their destruction, but is seen in a subset of SLE patients, not nearly all. *Raynaud's phenomena* - **Raynaud's phenomenon** is frequently associated with SLE and other connective tissue diseases, but it is not specific and occurs in many conditions, including primary Raynaud's without underlying disease. - It involves episodic vasospasm of small arteries, typically in the fingers and toes, in response to cold or stress. *Anti-ds DNA* - **Anti-double-stranded DNA (anti-dsDNA)** antibodies are highly specific for SLE and are crucial for diagnosis and monitoring disease activity, especially in lupus nephritis. - However, they are present in about 50-70% of SLE patients, making them less common than a positive ANA [1]. *Joint deformity* - **Joint deformity** can occur in some SLE patients, typically seen as **Jaccoud's arthropathy**, which is a reducible, non-erosive deformity. - Unlike rheumatoid arthritis, erosive joint damage and permanent fixed deformities are rare in SLE, and this is not a universal feature.

Question 1

According to American College of Rheumatology, all of the following are clinical criteria for the diagnosis of osteoarthritis, EXCEPT:

Accepted Answer

Atrophy of quadriceps muscles

Answer

Lack of warmth

Answer

Crepitus

Answer

Age > 50 years

Question 2

A 22-year-old man develops the insidious onset of low back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. Which test or group of tests would be most supportive of your suspected diagnosis?

Accepted Answer

An elevated sedimentation rate, a mild anemia on CBC, positive HLA-B27 in blood and sclerosis of the sacroiliac joints on plain films of the back.

Answer

Lumbosacral x-rays showing vertebral joint space narrowing and osteophyte formation at various levels.

Answer

A positive rheumatoid factor, anti-CCP, and an elevated C-reactive protein level.

Answer

MRI of the lumbosacral spine showing spinal compression fractures associated with bony destruction.

Question 3

A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis is

Accepted Answer

Antinuclear antibody

Answer

Rheumatoid factor

Answer

BUN and creatinine

Answer

ECG

Question 4

A young girl is admitted with joint pains and butterfly rash and positive urine proteinuria. The best test for her diagnosis is ?

Accepted Answer

Anti ds-DNA antibody

Answer

Antibodies to RNP

Answer

Antibodies to tRNA synthetase

Answer

Anti-centromere antibody

Question 5

False about Reactive arthritis

Accepted Answer

Acute purulent arthritis

Answer

Enthesitis of Achilles tendon

Answer

Precipitated by chlamydia

Answer

Indomethacin is the initial treatment of choice

Question 6

Most sensitive test for screening of SLE is

Accepted Answer

Anti-nuclear antibody

Answer

Rheumatoid factor test

Answer

Double-stranded DNA test

Answer

LE cell phenomenon

Question 7

Anti ds DNA is most specific for:

Accepted Answer

SLE

Answer

Polymyositis

Answer

Scleroderma

Answer

Rheumatoid arthritis

Question 8

All the following diseases are associated with HLA B-27 & Uveitis, except -

Accepted Answer

Behçet's syndrome

Answer

Ankylosing Spondylitis

Answer

Psoriasis

Answer

Reiter's syndrome

Question 9

Risk factors associated with development of Gout all except

Accepted Answer

Female sex

Answer

Thiazide

Answer

High fructose intake

Answer

Alcohol

Question 10

Which of the following is commonly seen in SLE?

Accepted Answer

↑ed ANA

Answer

Autoimmune hemolytic anaemia

Answer

Raynaud's phenomena

Answer

Anti-ds DNA

Answer

Joint deformity

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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