Rheumatology and Immunology Practice Questions

Q: All of the following are true regarding ankylosing spondylitis except:

50% of patients may have urinary infection. ***50% of patients may have urinary infection*** - Urinary tract infections are **not a characteristic feature** or a common complication of **ankylosing spondylitis**. - This statement is incorrect as there is no significant epidemiological or pathophysiological link between AS and a high incidence of UTIs. *Involvement of sacroiliac joint* - **Sacroiliitis**, inflammation of the sacroiliac joints, is one of the **hallmark features** and often the earliest sign of ankylosing spondylitis [1]. - It is typically **bilateral and symmetrical**, and its presence is crucial for diagnosis [1]. *Bamboo spine may be a radiological feature* - **Bamboo spine** is a characteristic late radiological finding in ankylosing spondylitis, resulting from **syndesmophyte formation** (ossification of spinal ligaments) and fusion of vertebral bodies [1]. - This appearance signifies severe spinal rigidity and advanced disease. *Most of people are HLAB27 positive* - The **HLA-B27 allele** is strongly associated with ankylosing spondylitis, being present in around **90% of Caucasian patients** [1]. - While not diagnostic on its own, its presence significantly increases susceptibility and supports the diagnosis in the right clinical context.

Q: Which of the following is NOT included in the diagnostic criteria for rheumatoid arthritis?

Swelling of any 2 joints of the body. ***Swelling of any 2 joints of the body*** - While **joint swelling** is a hallmark of rheumatoid arthritis [2], the diagnostic criteria, particularly the **2010 ACR/EULAR classification criteria**, specify involvement of certain joint counts or patterns, not just any two joints [1]. - The criteria focus on a **score-based system** that considers the number and type of affected joints (large vs. small), serumology (RF/anti-CCP), acute phase reactants, and duration of symptoms [1]. *Symmetric swelling* - **Symmetric polyarthritis** is a classic presentation of rheumatoid arthritis, often affecting the same joints on both sides of the body [2]. - This pattern helps differentiate RA from other forms of arthritis that tend to be asymmetric [2]. *Positive Rheumatoid factor* - **Rheumatoid factor (RF)** is an autoantibody found in a significant percentage of RA patients, and its presence is included in the diagnostic criteria [1]. - Along with **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, RF is an important serological marker for RA, especially aggressive disease [1]. *Morning stiffness* - **Morning stiffness** lasting for at least **30 minutes** (and often longer) is a characteristic symptom of inflammatory arthritis, including RA [2]. - This symptom reflects inflammation in the joints and typically improves with activity [2].

Q: A 45 year old female presents with the complaint of pain in the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints of both right and left hands. Serology showed positive anti-CCP antibodies. She was placed on infliximab for control. Which of the following need to tested before starting treatment?

PPD skin test. ***PPD skin test*** - **Infliximab** is a **TNF-alpha inhibitor**, which can **reactivate latent tuberculosis** (TB) by suppressing the immune response critical for containing the infection. [1] - A **PPD skin test** (or interferon-gamma release assay like Quantiferon) is essential to screen for latent TB before initiating treatment with biologics like infliximab to prevent severe active infection. [1] *G6PD* - **Glucose-6-phosphate dehydrogenase (G6PD) deficiency** is primarily relevant when prescribing drugs that can cause **hemolysis**, such as certain antimalarials or sulfonamides. - It does not have a direct interaction or contraindication with infliximab, and screening is not standard practice before starting TNF-alpha inhibitors. *Uric acid* - **Uric acid levels** are primarily monitored in conditions like **gout** or when using medications that affect uric acid metabolism. - They are not a standard pre-treatment screening test for patients starting infliximab for rheumatoid arthritis. *Complete blood count* - A **complete blood count (CBC)** is generally part of routine workup for many conditions and can help assess baseline blood cell counts before starting any significant medication. [1] - While useful for monitoring during treatment, it is not the critical specific test required to prevent a severe infectious complication, like a PPD test, before starting infliximab. [1]

Q: All of the following are associated with secondary Sjogren's syndrome EXCEPT

Pheochromocytoma. ***Pheochromocytoma*** - **Pheochromocytoma** is a tumor of the adrenal medulla that causes excessive secretion of **catecholamines** and is not directly associated with **secondary Sjögren's syndrome**. - Its clinical manifestations include **hypertension**, **tachycardia**, and **sweating**, which are distinct from autoimmune features. *Systemic lupus erythematosus* - **Systemic lupus erythematosus (SLE)** is a common autoimmune disease frequently associated with **secondary Sjögren's syndrome** [1]. - Patients with SLE can develop **sicca symptoms** (dry eyes, dry mouth) as a manifestation of secondary Sjögren's [1]. *Primary biliary cirrhosis* - **Primary biliary cirrhosis (PBC)** is an **autoimmune liver disease** that often coexists with other autoimmune conditions, including **secondary Sjögren's syndrome**. - Approximately 70% of patients with PBC have **sicca symptoms**, indicating an association with Sjögren's. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** is a chronic inflammatory autoimmune disease that is strongly associated with **secondary Sjögren's syndrome**. - Up to 30% of RA patients develop **dry eyes and mouth**, fulfilling the criteria for secondary Sjögren's.

Q: A 28-year-old male presents with chronic low back pain and morning stiffness for the past 6 months. The stiffness improves with physical activity and worsens with rest. He is HLA-B27 positive. Imaging shows bilateral sacroiliitis. What is the most probable diagnosis?

Ankylosing spondylitis. ***Ankylosing spondylitis*** - The presentation of **chronic low back pain**, **morning stiffness** that improves with activity and worsens with rest, **HLA-B27 positivity**, and **bilateral sacroiliitis** on imaging are classic diagnostic criteria for ankylosing spondylitis [1]. - It is a **chronic inflammatory disease** primarily affecting the axial skeleton leading to pain and progressive stiffness, often starting in young men [1]. *Osteopetrosis* - This is a rare genetic disorder characterized by **increased bone density** due to defective osteoclasts, leading to brittle bones and other systemic issues. - It does not present with the typical inflammatory back pain and sacroiliitis seen in this patient. *Diffuse idiopathic skeletal hyperostosis (DISH)* - DISH involves **ossification of ligaments and entheses**, particularly in the spine, forming "flowing osteophytes," but typically spares the sacroiliac joints. - It usually affects older individuals and is often *asymptomatic* or causes mild stiffness, without the strong inflammatory pattern or sacroiliitis. *OA spine* - **Osteoarthritis** of the spine typically causes mechanical back pain that **worsens with activity** and improves with rest, in contrast to the patient's symptoms [2]. - It is characterized by cartilage degradation and osteophyte formation, but not by inflammatory sacroiliitis or HLA-B27 association.

Q: HLA B27 histocompatibility antigen is correlated with -

Ankylosing spondylitis. ***Ankylosing spondylitis*** - **HLA-B27** is strongly associated with **ankylosing spondylitis**, found in over 90% of affected individuals [1]. - This genetic predisposition plays a significant role in the pathogenesis of this **chronic inflammatory arthritis** primarily affecting the spine and sacroiliac joints. *Felty's syndrome* - Felty's syndrome is a severe, rare complication of **rheumatoid arthritis** characterized by **neutropenia** and **splenomegaly**. - It is not directly correlated with **HLA-B27** but rather with the presence of **rheumatoid factor** and anti-CCP antibodies. *Scleroderma* - **Scleroderma**, or systemic sclerosis, is an autoimmune connective tissue disease characterized by **fibrosis of the skin and internal organs**. - While it has genetic associations, **HLA-B27** is not a primary marker; associations are more commonly seen with other HLA alleles like **HLA-DRB1**. *Sjogren's disease* - **Sjogren's disease** is an autoimmune disorder primarily affecting the **lacrimal and salivary glands**, leading to dry eyes and dry mouth. - Its genetic associations are mainly with **HLA-DR3** and **HLA-DQB1**, not **HLA-B27**.

Q: A 70-year-old woman is seen by her physician for evaluation of severe headaches. She noted these several weeks ago, and they have been getting worse. Although she has not had any visual aura but she has been intermittently losing vision in her left eye for the last few days. She denies new weakness or numbness, but she does reports jaw pain with eating. Her past medical history includes coronary artery disease requiring a bypass grafting 10 years prior, diabetes mellitus, hyperlipidaemia, and mild depression. Full review of symptoms is notable for night sweats and mild low back pain particularly prominent in the morning. Which of the following is the next most appropriate step?

Immediate initiation of glucocorticoid. ### Immediate initiation of glucocorticoids - The patient's symptoms, including **severe headaches**, **transient vision loss (amaurosis fugax)**, **jaw claudication**, and **systemic symptoms** like night sweats in an elderly woman, are highly suggestive of **giant cell arteritis (GCA)**. [1] - **Prompt initiation of high-dose glucocorticoids** is crucial to prevent irreversible vision loss, which is a devastating complication of GCA. [1] *Aspirin 975 mg orally daily* - While aspirin may be considered as an adjunct in treating GCA to reduce thrombotic complications, it is **not the primary or immediate treatment** for the disease itself. - **High-dose aspirin** is typically not used for GCA and would not address the underlying inflammation causing ocular ischemia. *Measurement of erythrocyte sedimentation rate* - An **elevated ESR** is characteristic of GCA and can support the diagnosis. [1] - However, performing this test first would **delay crucial treatment** for GCA, potentially leading to permanent vision loss. [1] *Referral for temporal artery biopsy* - A **temporal artery biopsy** is the gold standard for confirming the diagnosis of GCA but should **not delay the initiation of glucocorticoids**. [1] - Treatment should begin immediately based on clinical suspicion, and the biopsy can be performed safely within **1-2 weeks of starting steroids** without significantly impacting diagnostic yield. [1]

Q: Uveo-parotitis is seen in

Sarcoidosis. ***Sarcoidosis*** - **Uveo-parotitis** (also known as Heerfordt's syndrome or uveoparotid fever) is a rare manifestation of **sarcoidosis**, characterized by swelling of the **parotid glands**, anterior **uveitis**, fever, and sometimes facial nerve palsy [1]. - Sarcoidosis is a chronic inflammatory disease that can affect multiple organs, with **granuloma formation** being its pathological hallmark [1]. *Mumps* - Mumps primarily causes **parotitis**, an inflammation of the parotid glands, but it is typically not associated with **uveitis**. - It is a viral infection characterized by sudden onset of fever, headache, malaise, myalgia, and swelling of one or both parotid glands. *Measles* - Measles is a viral infection that causes a **generalized maculopapular rash**, fever, cough, coryza, and conjunctivitis, but it does not cause **uveo-parotitis**. - Ocular involvement in measles is usually limited to **conjunctivitis** rather than deeper inflammatory conditions like uveitis. *Cystic fibrosis* - **Cystic fibrosis** is a genetic disorder affecting exocrine glands, leading to thick mucus production in the lungs, pancreas, and other organs. - While it can lead to various systemic complications, it is not associated with **uveo-parotitis**.

Q: Characteristic feature of SLE is -

Polyserositis. ***Polyserositis*** - **Polyserositis**, including **pleuritis** and **pericarditis**, is a common and characteristic manifestation of **Systemic Lupus Erythematosus (SLE)**, affecting a significant portion of patients [1]. - Inflammation of serous membranes leads to chest pain, effusions, and effacement of normal tissue planes [1]. *Cavitating lesion in lung* - **Cavitating lung lesions** are generally not a characteristic feature of SLE; they are more commonly associated with infections (e.g., tuberculosis, fungal infections), vasculitis (e.g., granulomatosis with polyangiitis), or malignancies. - While SLE can cause pulmonary manifestations like **lupus pneumonitis** or **diffuse alveolar hemorrhage**, these typically do not present as cavitating lesions [1]. *Joint deformity* - Although **arthralgias** and **arthritis** are very common in SLE, leading to pain and swelling, **non-erosive arthritis** is the hallmark. - Significant **joint deformities** (e.g., erosions, subluxations) are rare in SLE and are more characteristic of conditions like **rheumatoid arthritis** (with its destructive synovitis). *Uveitis* - **Uveitis** (inflammation of the uvea of the eye) is not a common or characteristic manifestation of SLE. - It is more typically associated with other systemic inflammatory conditions such as **spondyloarthropathies** (e.g., ankylosing spondylitis), **sarcoidosis**, or **Behcet's disease**.

Question 1

All of the following are true regarding ankylosing spondylitis except:

Accepted Answer

50% of patients may have urinary infection

Answer

Involvement of sacroiliac joint

Answer

Bamboo spine may be a radiological feature

Answer

Most of people are HLAB27 positive

Question 2

Which of the following is NOT included in the diagnostic criteria for rheumatoid arthritis?

Accepted Answer

Swelling of any 2 joints of the body

Answer

Symmetric swelling

Answer

Positive Rheumatoid factor

Answer

Morning stiffness

Question 3

A 45 year old female presents with the complaint of pain in the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints of both right and left hands. Serology showed positive anti-CCP antibodies. She was placed on infliximab for control. Which of the following need to tested before starting treatment?

Accepted Answer

PPD skin test

Answer

G6PD

Answer

Uric acid

Answer

Complete blood count

Question 4

All of the following are associated with secondary Sjogren's syndrome EXCEPT

Accepted Answer

Pheochromocytoma

Answer

Systemic lupus erythematosus

Answer

Primary biliary cirrhosis

Answer

Rheumatoid arthritis

Question 5

A 28-year-old male presents with chronic low back pain and morning stiffness for the past 6 months. The stiffness improves with physical activity and worsens with rest. He is HLA-B27 positive. Imaging shows bilateral sacroiliitis. What is the most probable diagnosis?

Accepted Answer

Ankylosing spondylitis

Answer

Osteopetrosis

Answer

Diffuse idiopathic skeletal hyperostosis (DISH)

Answer

OA spine

Question 6

HLA B27 histocompatibility antigen is correlated with -

Accepted Answer

Ankylosing spondylitis

Answer

Felty's syndrome

Answer

Scleroderma

Answer

Sjogren's disease

Question 7

A 70-year-old woman is seen by her physician for evaluation of severe headaches. She noted these several weeks ago, and they have been getting worse. Although she has not had any visual aura but she has been intermittently losing vision in her left eye for the last few days. She denies new weakness or numbness, but she does reports jaw pain with eating. Her past medical history includes coronary artery disease requiring a bypass grafting 10 years prior, diabetes mellitus, hyperlipidaemia, and mild depression. Full review of symptoms is notable for night sweats and mild low back pain particularly prominent in the morning. Which of the following is the next most appropriate step?

Accepted Answer

Immediate initiation of glucocorticoid

Answer

Aspirin 975 mg orally daily

Answer

Measurement of erythrocyte sedimentation rate

Answer

Referral for temporal artery biopsy

Question 8

A 40-year-old female patient presented to the OPD with joint pain in the wrist, MCP, PIP and DIP joints B/L. The involved joints were tender and swollen. Patient also gave a history of certain skin lesions which occurred before the joints were involved along with certain nail changes were also seen. Lab findings revealed HLA-B27 positivity. Which of the following x-ray findings most commonly correlates with the above condition?

Accepted Answer

Option A shows pencil in cup deformity- seen in psoriatic arthritis

Answer

Option B shows Z-deformity - seen in RA

Answer

Option C shows spade phalanx - seen in acromegaly

Answer

All of the options are seen.

Question 9

Uveo-parotitis is seen in

Accepted Answer

Sarcoidosis

Answer

Mumps

Answer

Measles

Answer

Cystic fibrosis

Question 10

Characteristic feature of SLE is -

Accepted Answer

Polyserositis

Answer

Cavitating lesion in lung

Answer

Joint deformity

Answer

Uveitis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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