Rheumatology and Immunology Practice Questions

Q: Arthritis mutilans is due to:

Psoriatic arthritis. ***Psoriatic arthritis*** - **Arthritis mutilans** is a severe and destructive form of **psoriatic arthritis** characterized by rapid bone resorption and telescoping digits [1]. - It results in significant **deformity** and functional impairment, particularly in the hands and feet [1]. *Rheumatoid arthritis* - While rheumatoid arthritis can cause severe joint destruction, it typically presents with **symmetrical polyarthritis** and joint erosions, but not the specific "telescoping digit" deformity seen in arthritis mutilans. - It more commonly leads to deformities like **ulnar deviation** and **swan-neck deformities**. *Osteoarthritis* - Osteoarthritis is a degenerative joint disease characterized by **cartilage loss** and **osteophyte formation**, primarily affecting weight-bearing joints. - It does not cause the rapid bone resorption or inflammatory damage characteristic of arthritis mutilans. *Rheumatic arthritis* - This term is ambiguous; if referring to **rheumatic fever arthritis**, it is a migratory polyarthritis following a Group A Streep infection and is transient, not leading to chronic destructive deformities like arthritis mutilans. - If referring to a general inflammatory arthritis, it lacks the specificity for diagnosing arthritis mutilans.

Q: In rheumatoid arthritis, the characteristic joint involvement is:

Metacarpophalangeal joint. ***Metacarpophalangeal joint*** - **Rheumatoid arthritis** classically affects the **small joints** of the hands and feet in a **symmetrical** pattern [1]. - The **metacarpophalangeal (MCP) joints** are among the most frequently involved, leading to pain, swelling, and characteristic deformities [1]. *Hip joint* - While **hip involvement** can occur in late-stage or severe rheumatoid arthritis, it is not considered the **characteristic initial presentation** of the disease. - Initial symptoms usually present in smaller, more peripheral joints. *Spine* - **Spinal involvement** in rheumatoid arthritis primarily affects the **cervical spine**, particularly the atlantoaxial joint, which can lead to **subluxation** [1]. - However, the lumbar and thoracic spine are typically spared, and it is not the initial characteristic joint involvement [1]. *Knee* - The **knee joint** can be affected in rheumatoid arthritis, often presenting with **synovitis and effusion**. - It is a **larger joint** and while common, it is not as characteristic of the initial defining joint involvement as the MCP joints [1].

Q: Which of the following conditions results in arthritis without erosion of the bones?

SLE. ***SLE*** - **Systemic lupus erythematosus (SLE)** arthritis is typically **non-erosive**, meaning it usually doesn't cause damage to the bone or cartilage, though it can cause joint deformities like **Jaccoud's arthropathy** [1]. - The inflammation in SLE primarily affects the **synovium** and surrounding soft tissues without directly eroding the articular surfaces [1]. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** is characterized by **erosive arthritis**, where chronic inflammation of the synovium leads to destruction of articular cartilage and **subchondral bone erosions**. - These erosions are visible on **radiographs** and are a hallmark of the disease progression. *Psoriasis* - **Psoriatic arthritis** can be **erosive**, especially in its more severe forms, leading to **"pencil-in-cup" deformities** and destruction of joint structures [1]. - While some forms may be less aggressive, significant **bone erosion** is a recognized feature [1]. *Osteoarthritis* - **Osteoarthritis** is characterized by the **degeneration of cartilage** and subsequent changes in subchondral bone, including **osteophyte formation** and **subchondral sclerosis**, rather than direct erosion. - While it involves structural changes to the bone and cartilage, it's not typically described as an erosive arthritis in the same sense as inflammatory arthropathies, but rather a degenerative process that leads to **cartilage loss** and **bone remodeling**.

Q: An elderly male presents with pain in his shoulders and hips. Temporal arteries are tender to palpation. ESR is 105 mm/L.

Temporal arteritis. ***Temporal arteritis*** - This condition presents with **shoulder and hip pain (polymyalgia rheumatica-like symptoms)**, **tender temporal arteries**, and a **markedly elevated ESR**, all classic features of giant cell arteritis (temporal arteritis). - It is a **large vessel vasculitis** predominantly affecting individuals over 50 years of age and can lead to irreversible **blindness** if not treated promptly. [1] *Granulomatosis with polyangiitis (Wegener granulomatosis)* - Primarily affects the **upper and lower respiratory tracts** and **kidneys**, often presenting with chronic sinusitis, lung nodules, and glomerulonephritis. [1] - While it can cause an elevated ESR, the primary symptoms described (shoulder/hip pain, tender temporal arteries) are not typical of this condition. *Cryoglobulinemic vasculitis* - This vasculitis is often associated with **hepatitis C infection** and typically presents with **palpable purpura**, **arthralgias**, and **glomerulonephritis**, none of which are described. - It primarily involves **small to medium-sized vessels** and does not typically manifest with tender temporal arteries or polymyalgia rheumatica. *Churg-Strauss syndrome* - This condition, now known as **eosinophilic granulomatosis with polyangiitis**, is characterized by **asthma**, **eosinophilia**, and **multi-organ involvement**. [2] - While it is a systemic vasculitis and can cause musculoskeletal pain, the specific presentation of tender temporal arteries and polymyalgia rheumatica is not its hallmark. [2]

Q: What are the extra-articular manifestations of RA?

All of the options. ***All of the options*** - **Rheumatoid arthritis (RA)** is a systemic inflammatory disease that can affect multiple organs beyond the joints [1]. Therefore, **pericarditis**, **pulmonary fibrosis**, and **scleritis** are all recognized extra-articular manifestations [2]. - The presence of various extra-articular features often indicates more severe or long-standing disease and is associated with increased morbidity and mortality in RA patients. *Pericarditis* - **Pericarditis** is a recognized cardiovascular manifestation of RA, involving inflammation of the **pericardium**. - While many cases are asymptomatic, it can cause chest pain and, rarely, **pericardial effusion** or **constrictive pericarditis**. *Pulmonary fibrosis* - **Interstitial lung disease (ILD)**, including **pulmonary fibrosis**, is a significant pulmonary complication of RA [2]. - It can lead to progressive shortness of breath, cough, and is a major cause of morbidity and mortality in RA patients. *Scleritis* - **Scleritis** is an ocular manifestation of RA, presenting as severe inflammation of the sclera (the white outer layer of the eyeball) [1]. - It can cause severe pain, redness, and vision changes, and requires prompt treatment to prevent visual impairment [1].

Q: True statements about ankylosing spondylitis include all except: a) HLA-B27 is found in 90% of sufferers b) Uveitis is found in 15 to 20% of sufferers c) The condition is more common in females d) Radiological changes can occur in the spine before symptoms

BCD. ***BCD*** - This option correctly identifies the statement "The condition is more common in females" as false, making it an **incorrect statement** about ankylosing spondylitis. Also, the statement "Radiological changes can occur in the spine before symptoms" is true. This option is consistent with the prompt to find all *except*. - Ankylosing spondylitis is significantly **more common in males** than females, with a male-to-female ratio of about 2-3:1, thus making the original statement (c) false. *AC* - This option incorrectly states that "HLA-B27 is found in 90% of sufferers" is false. **HLA-B27** is indeed found in about 90-95% of individuals with ankylosing spondylitis, making statement (a) true [1]. - This option also incorrectly states that the condition being more common in females is true, when it is actually **more common in males**. *ACD* - This option incorrectly includes statement (a) as false; **HLA-B27** is found in the vast majority of patients with ankylosing spondylitis [1]. - It also incorrectly implies that statements (c) and (d) are false when (c) is false (making the condition more common in females an incorrect statement) and (d) is true. **Radiographic changes** such as sacroiliitis can precede overt symptoms in some patients [1]. *BD* - This option incorrectly implies that "Uveitis is found in 15 to 20% of sufferers" is false [1]. **Acute anterior uveitis** is a common extra-articular manifestation, occurring in 25-40% of patients with ankylosing spondylitis. - It also includes that "Radiological changes can occur in the spine before symptoms" is false, which is incorrect. **Subclinical inflammation** and early radiological changes often precede the development of clinical symptoms [1].

Q: A 40-year-old female presents with a history of fever, fatigue, weight loss, and polyarthralgia. Based on these symptoms, what is the most likely diagnosis?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Fever**, **fatigue**, **weight loss**, and **polyarthralgia** are classic systemic symptoms often seen in the initial presentation of rheumatoid arthritis, reflecting its systemic inflammatory nature. - While other conditions can cause polyarthralgia, the combination with constitutional symptoms makes rheumatoid arthritis a strong consideration, often preceding the development of overt joint deformities. *Gout* - Gout typically presents as **acute, severe monoarticular arthritis**, often affecting the great toe, rather than widespread polyarthralgia. - Systemic symptoms like significant fever, fatigue, and weight loss are less common in gout, especially in its early stages. *Osteoarthritis* - Osteoarthritis is a **degenerative joint disease** primarily characterized by joint pain that worsens with activity and improves with rest. - It generally does not present with systemic symptoms such as fever, significant fatigue, or unexplained weight loss, as it is not a systemic inflammatory condition. *Psoriatic arthritis* - Psoriatic arthritis is associated with **skin psoriasis** and often presents with **asymmetric oligoarthritis** or dactylitis. - While some constitutional symptoms might occur, the combination of strong systemic features described makes rheumatoid arthritis a more fitting initial diagnosis in the absence of psoriatic skin lesions.

Q: About fibromyalgia all are true except

More common in males than females. ***More common in males than females*** - Fibromyalgia is significantly **more prevalent in females** than in males, with a female-to-male ratio ranging from 2:1 to 7:1 in various studies. - The exact reasons for this gender disparity are still under investigation, but hormonal, genetic, and psychosocial factors are thought to play a role. *Associated with EEG abnormalities* - Patients with fibromyalgia often exhibit **abnormal EEG patterns**, particularly during sleep, characterized by an alpha rhythm intrusion into non-REM sleep [1]. - These EEG abnormalities are thought to contribute to the characteristic **non-restorative sleep** experienced by many fibromyalgia patients [1]. *Associated with decreased blood flow to the brain* - Studies using imaging techniques like **SPECT** and **fMRI** have shown areas of **reduced cerebral blood flow** in patients with fibromyalgia, particularly in regions involved in pain processing [1]. - This decreased blood flow may contribute to the cognitive symptoms, such as **"fibro fog"**, and altered pain perception [1]. *Associated with low free cortisol levels* - Fibromyalgia is often associated with dysregulation of the **hypothalamic-pituitary-adrenal (HPA) axis**, leading to abnormalities in cortisol secretion [1]. - While total cortisol levels can be variable, many studies report **lower free cortisol levels**, particularly during daytime hours, reflecting a blunted stress response [1].

Q: 35 year old female patient complains of dry mouth and scratchy feeling in eyes. She is found to have antibodies against anti- SSA/Ro. Which of the following can be the most accurate sole criterion to diagnose the condition

Lip tissue biopsy. Lip tissue biopsy - A lip biopsy demonstrating focal lymphocytic sialadenitis in the minor salivary glands is a gold standard for diagnosing Sjogren's syndrome, especially when other criteria are met. - This pathological finding provides definitive evidence of the characteristic autoimmune inflammation affecting the exocrine glands. Objective measurement of lacrimal and salivary gland secretion - While important for evaluating the severity of dryness (e.g., Schirmer's test for eyes, sialometry for saliva), these are functional measurements and not a sole diagnostic criterion. - They can be affected by other factors and do not directly confirm the autoimmune pathology like a biopsy does. Lymph node biopsy - A lymph node biopsy is not a standard diagnostic procedure for Sjogren's syndrome. - It might be performed if lymphoma is suspected, as Sjogren's patients have an increased risk, but it's not used for initial diagnosis of the syndrome itself. Positive rheumatoid factor - A positive rheumatoid factor (RF) is common in Sjogren's syndrome (present in 75-90% of patients), but it is not specific and can be elevated in other autoimmune diseases (e.g., rheumatoid arthritis) or even in healthy individuals. - Therefore, it cannot be used as a sole diagnostic criterion. Antibodies to Ro (SSA) are characteristic of the condition and are often found in association with anti-La antibodies [1].

Q: HLA associated with rheumatoid arthritis is?

HLA DR 4. ***HLA DR 4*** - **HLA-DR4** is the **most strongly associated HLA allele** with **rheumatoid arthritis (RA)**, particularly in individuals of European descent. - The presence of this allele increases an individual's susceptibility to developing RA and is often linked to more severe disease. *HLA DR2* - **HLA-DR2** is associated with other autoimmune conditions like **multiple sclerosis** and **narcolepsy**, but not primarily with rheumatoid arthritis. - While it is an HLA class II allele, its role in RA susceptibility is not significant. *HLA B27* - **HLA-B27** is a Class I major histocompatibility complex (MHC) allele **strongly associated with seronegative spondyloarthropathies**, such as ankylosing spondylitis and reactive arthritis [1]. - It is not directly linked to rheumatoid arthritis, which is typically seropositive (RF and anti-CCP positive). *HLA-B9* - **HLA-B9** is not a commonly recognized or significant HLA allele associated with increased risk for any specific autoimmune disease, including rheumatoid arthritis. - No strong clinical or genetic association exists between HLA-B9 and RA.

Question 1

Arthritis mutilans is due to:

Accepted Answer

Psoriatic arthritis

Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Rheumatic arthritis

Question 2

In rheumatoid arthritis, the characteristic joint involvement is:

Accepted Answer

Metacarpophalangeal joint

Answer

Hip joint

Answer

Spine

Answer

Knee

Question 3

Which of the following conditions results in arthritis without erosion of the bones?

Accepted Answer

SLE

Answer

Rheumatoid arthritis

Answer

Psoriasis

Answer

Osteoarthritis

Question 4

An elderly male presents with pain in his shoulders and hips. Temporal arteries are tender to palpation. ESR is 105 mm/L.

Accepted Answer

Temporal arteritis

Answer

Granulomatosis with polyangiitis (Wegener granulomatosis)

Answer

Cryoglobulinemic vasculitis.

Answer

Churg-Strauss syndrome

Question 5

What are the extra-articular manifestations of RA?

Accepted Answer

All of the options

Answer

Pericarditis

Answer

Pulmonary fibrosis

Answer

Scleritis

Question 6

True statements about ankylosing spondylitis include all except: a) HLA-B27 is found in 90% of sufferers b) Uveitis is found in 15 to 20% of sufferers c) The condition is more common in females d) Radiological changes can occur in the spine before symptoms

Accepted Answer

BCD

Answer

AC

Answer

ACD

Answer

BD

Question 7

A 40-year-old female presents with a history of fever, fatigue, weight loss, and polyarthralgia. Based on these symptoms, what is the most likely diagnosis?

Accepted Answer

Rheumatoid arthritis

Answer

Gout

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Question 8

About fibromyalgia all are true except

Accepted Answer

More common in males than females

Answer

Associated with EEG abnormalities

Answer

Associated with decreased blood flow to the brain

Answer

Associated with low free cortisol levels

Question 9

35 year old female patient complains of dry mouth and scratchy feeling in eyes. She is found to have antibodies against anti- SSA/Ro. Which of the following can be the most accurate sole criterion to diagnose the condition

Accepted Answer

Lip tissue biopsy

Answer

Objective measurement of lacrimal and salivary gland secretion

Answer

Lymph node biopsy

Answer

Positive rheumatoid factor

Question 10

HLA associated with rheumatoid arthritis is?

Accepted Answer

HLA DR 4

Answer

HLA DR2

Answer

HLA B27

Answer

HLA-B9

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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