Rheumatology and Immunology Practice Questions

Q: Joint not involved in RA ?

DIP. ***DIP*** - The **distal interphalangeal (DIP)** joints are characteristically spared in **rheumatoid arthritis (RA)**, which helps differentiate it from other inflammatory arthropathies like psoriatic arthritis [1]. - Involvement of the DIP joints would suggest a different diagnosis, such as **osteoarthritis** or **psoriatic arthritis** [3]. *PIP* - The **proximal interphalangeal (PIP)** joints are very commonly involved in **rheumatoid arthritis (RA)**, causing pain, swelling, and characteristic **boutonnière** or **swan neck deformities** [1], [2]. - RA typically causes symmetrical polyarthritis of the small joints, with PIP joints being a primary target [2]. *Wrist* - The **wrist joints** are frequently affected in **rheumatoid arthritis (RA)**, often leading to significant pain, swelling, and limited range of motion. - Inflammatory changes in the wrist contribute to deformities and functional impairment seen in RA patients. *MCP* - The **metacarpophalangeal (MCP)** joints are a hallmark site of involvement in **rheumatoid arthritis (RA)**, experiencing early and significant inflammation [2]. - Involvement of the MCP joints often leads to characteristic **ulnar deviation** of the fingers.

Q: Palpable purpura is seen in all conditions except

Giant cell arteritis. ***Giant cell arteritis*** - **Giant cell arteritis** primarily affects **large- and medium-sized arteries**, most commonly the **temporal artery**. - It typically manifests with **headache**, **jaw claudication**, and **visual disturbances**, but **palpable purpura** is not a characteristic skin finding. *Cryoglobulinuria* - **Cryoglobulinemia** is characterized by the presence of **cryoglobulins** in the blood, which can precipitate in cold temperatures. - This often leads to **cutaneous small vessel vasculitis**, manifesting as **palpable purpura**, particularly on the lower extremities [1]. *H. S. Purpura* - **Henoch-Schonlein Purpura (HSP)**, now known as **IgA vasculitis**, is a systemic vasculitis primarily affecting small vessels [1]. - Its hallmark dermatological feature is **palpable purpura**, typically found on the **buttocks and lower extremities**, often accompanied by arthralgia, abdominal pain, and renal involvement [1]. *Drug induced vasculitis* - **Drug-induced vasculitis** is an immune-mediated reaction to certain medications that can cause inflammation of blood vessels. - This condition frequently presents with **palpable purpura**, along with other symptoms like fever, arthralgia, and myalgia, due to the acute inflammation of small blood vessels in the skin.

Q: BASDAI criteria is indicated in

Ankylosing spondylitis. ***Ankylosing spondylitis*** - The **Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)** is a commonly used patient-reported outcome measure specifically designed to assess disease activity and symptoms in patients with **ankylosing spondylitis** [1]. - It evaluates five key symptoms: **fatigue, spinal pain, peripheral joint pain/swelling, enthesitis, and morning stiffness**, along with the duration of morning stiffness [1]. *Any autoimmune disease* - While BASDAI is used in an autoimmune disease, it is **not applicable to all autoimmune diseases** due to their diverse manifestations and affected systems. - Each autoimmune disease often has its own **specific criteria or indices** to measure disease activity and monitor treatment response. *Kawasaki Disease* - **Kawasaki disease** is a childhood vasculitis primarily affecting medium-sized arteries, and its diagnostic and activity criteria are distinct from BASDAI. - Disease activity in Kawasaki disease is monitored by different clinical features and laboratory markers such as **fever, rash, conjunctivitis, and inflammatory markers**. *Rheumatoid Arthritis* - **Rheumatoid arthritis (RA)** is a chronic inflammatory autoimmune disease primarily affecting synovial joints, and its disease activity is assessed using scales like **DAS28 (Disease Activity Score 28)**. - Although RA and ankylosing spondylitis are both arthritic conditions, their clinical presentation, affected joints, and systemic involvement differ, necessitating different assessment tools.

Q: Which of the following statements regarding Rheumatoid arthritis is false?

Pulmonary nodules are present. Everything regarding Rheumatoid arthritis follows a predictable clinical pattern. [1] ***Pulmonary nodules are present*** - While **rheumatoid arthritis** can cause pulmonary manifestations, the presence of **pulmonary nodules** is a specific, though less common, finding. [1] This statement is framed as generally true, but in the context of a "false" question about RA characteristics, it's considered false because not all RA patients have them, and this is a distractor to a clear, established finding in RA like **juxta-articular osteoporosis**, leading to further options like "none of the above". It's often used to differentiate it from other conditions. - The phrasing "pulmonary nodules are present" suggests a universal presence, which is not accurate. **Rheumatoid nodules** can occur in the lungs but are not a defining or constant feature across all cases. [1] *Juxta articular osteoporosis may be present* - **Juxta-articular osteoporosis** is a common and early radiological feature of **rheumatoid arthritis** due to chronic inflammation affecting bone density near the joints. [1] - This statement is true; **bone erosions** and **osteoporosis** are characteristic findings in RA. [1] *None of the above* - This option is incorrect because the statement "Pulmonary nodules are present" is indeed false when interpreted as a universal characteristic of rheumatoid arthritis. - Therefore, at least one of the previous statements (the first one) is false, making this option inappropriate. *It is symmetrical involving small and large joints* - **Rheumatoid arthritis** typically affects joints in a **symmetrical pattern**, affecting both small joints (hands, feet) and larger joints (knees, shoulders) over time. [1] - This statement accurately describes a key clinical characteristic of **rheumatoid arthritis**, making it a true statement. [1]

Q: A young man back from leisure trip has swollen knee joints & foreign body sensation in eyes. Likely cause is -

Reiter's syndrome. REITER'S SYNDROME [1] - Reiter's syndrome, also known as **reactive arthritis**, is characterized by the classic triad of **arthritis**, **conjunctivitis** (foreign body sensation in eyes), and **urethritis** [1]. - It often develops after a **genitourinary or gastrointestinal infection**, which aligns with a recent leisure trip [1]. *Behcet's disease* - Behcet's disease primarily presents with recurrent **oral and genital ulcers**, along with **uveitis** and **skin lesions**. - While arthritis can occur, the combination of specific eye foreign body sensation and a recent trip isn't as characteristic as for Reiter's. *SLE* - **Systemic lupus erythematosus (SLE)** is a systemic autoimmune disease with diverse manifestations, including polyarthritis and serositis. - **Conjunctivitis** as a primary eye symptom or a direct association with a preceding infection/trip is less typical compared to Reiter's syndrome. *Sarcoidosis* - **Sarcoidosis** is a multisystem inflammatory disease often involving the **lungs, skin, and lymph nodes**, and can cause arthritis. - However, its acute presentation with foreign body sensation in the eyes and post-trip history is not its common debut.

Q: Which of the following is seen in Rheumatoid Arthritis?

All of the above. ***All of the above*** - **Rheumatoid arthritis** is an autoimmune disease characterized by chronic inflammation that can affect various body systems, and the presence of **Rheumatoid Factor (RF)**, **Anti-Cyclic Citrullinated Peptide (Anti-CCP) antibodies**, and a **higher risk of extra-articular manifestations** are all characteristic features [1]. - While RF and anti-CCP are diagnostic markers, extra-articular manifestations highlight the systemic nature of the disease, affecting organs beyond the joints. *Presence of Rheumatoid Factor (RF)* - While many patients with **rheumatoid arthritis** test positive for **RF**, it is not specific to RA and can be seen in other conditions, such as systemic lupus erythematosus, Sjögren's syndrome, and chronic infections [1]. - Approximately 20% of RA patients are seronegative for RF. *Presence of Anti-CCP antibodies* - **Anti-CCP antibodies** are highly specific for **rheumatoid arthritis** and often appear early in the disease course, making them a valuable diagnostic and prognostic marker [1]. - Their presence is strongly associated with an erosive disease course. *Higher risk of extra-articular manifestations* - **Extra-articular manifestations** of **rheumatoid arthritis** indicate systemic involvement and can include rheumatoid nodules, vasculitis, pleuritis, pericarditis, scleritis, and Felty's syndrome [1]. - The presence of these manifestations often correlates with more severe disease and a poorer prognosis [1].

Q: A 24-year-old woman presents with abdominal pain, joint discomfort, and lower limb rash. She was well until 1 week before presentation. On examination, she has a palpable purpuric rash on her legs, nonspecific abdominal discomfort, and no active joints. She has 3+ proteinuria, normal WBC, no eosinophils, and elevated creatinine of 1.6 mg/dL. Biopsy of the rash confirms vasculitis with immunoglobulin A (IgA) 3+and C3 (complement 3) deposition on immunofluorescence.For the above patient with vasculitis syndrome, select the most likely diagnosis.

Henoch-Schonlein purpura. ***Henoch-Schonlein purpura*** - The classic triad of **palpable purpura**, **arthralgia**, and **abdominal pain**, along with **renal involvement (proteinuria, elevated creatinine)**, strongly suggests Henoch-Schonlein purpura (HSP) [1]. - **IgA deposition** on biopsy of the rash is the hallmark of HSP, confirming its diagnosis [1]. *vasculitis associated with infectious diseases* - While infections can trigger vasculitis, the specific presentation with **IgA deposition**, palpable purpura, and prominent gastrointestinal/renal involvement points away from this broad category [1]. - No clear infectious trigger or specific pathogen is mentioned, making a more specific diagnosis like HSP more appropriate given the findings. *Churg-Strauss disease* - Characterized by **asthma**, **eosinophilia**, and **granulomatous inflammation**, none of which are present in this patient (normal WBC, no eosinophils mentioned) [1]. - Typically involves **ANCA-positive vasculitis (MPO-ANCA)**, which is not indicated here, and IgA deposition is not a characteristic feature [1]. *polyarteritis nodosa (PAN)* - Primarily affects **medium-sized arteries** and can cause **aneurysms** and **organ ischemia**, but classically spares the capillaries and does not involve IgA deposition or palpable purpura. - Often associated with **hepatitis B infection** and lacks the prominent skin and renal manifestations of HSP with IgA deposition.

Q: Which maternal antibody is responsible for heart block in a baby born to a mother suffering from SLE?

Anti-Ro antibody. ***Anti-Ro antibody*** - **Anti-Ro (SS-A)** antibodies are strongly associated with **neonatal lupus** and its most severe manifestation, congenital heart block. - These antibodies can cross the placenta and target fetal cardiac tissue, leading to irreversible damage to the **atrioventricular node**. *Anti-Sm antibody* - **Anti-Sm (Smith)** antibodies are highly specific for **Systemic Lupus Erythematosus (SLE)** and are associated with severe disease activity, but not directly linked to congenital heart block. - They target components of the **spliceosome** and are considered a diagnostic marker for SLE. *Anti-RNP antibody* - **Anti-RNP (ribonucleoprotein)** antibodies are associated with **Mixed Connective Tissue Disease (MCTD)** and can be present in SLE, but they are not the primary cause of neonatal lupus or congenital heart block. - High titers of anti-RNP antibodies are often linked to features like **Raynaud's phenomenon**, **myositis**, and **sclerodactyly**. *Anti-dsDNA antibody* - **Anti-dsDNA (double-stranded DNA)** antibodies are highly specific for **SLE** and correlate with disease activity, particularly with **lupus nephritis**. - While important in SLE diagnosis and monitoring, they are not directly implicated in the pathogenesis of **congenital heart block** in neonates.

Q: Most common presentation of cardiac lupus ?

Pericarditis. ***Pericarditis*** - **Pericarditis** is the most common cardiac manifestation of **systemic lupus erythematosus (SLE)**, affecting a significant proportion of patients. - It often presents as **chest pain** that improves with leaning forward and worsens with lying down, along with a **pericardial friction rub** [3]. *Aortic regurgitation* - While **valvular disease** can occur in lupus, **aortic regurgitation** is less common than pericarditis as the initial or most frequent cardiac presentation. - Valvular involvement, particularly **Libman-Sacks endocarditis**, can sometimes lead to regurgitation, but is itself less common than pericardial involvement [2]. *Libman sacks endocarditis* - **Libman-Sacks endocarditis** involves **non-infectious vegetative lesions** on heart valves, typically the mitral or aortic valves. - Although characteristic of lupus, it is a less frequent presentation compared to **pericarditis** and can lead to valvular dysfunction. *Myocarditis* - **Myocarditis**, or inflammation of the heart muscle, is a less common but more serious cardiac manifestation of SLE [1]. - It can cause **heart failure** and **arrhythmias** but is not the most common initial presentation.

Q: True regarding felty's syndrome is all, except -

Nephropathy. ***Nephropathy*** - **Nephropathy** is not a characteristic component of Felty's syndrome; the triad specifically involves rheumatoid arthritis, neutropenia, and splenomegaly [1]. - While patients with rheumatoid arthritis can develop renal complications, they are not directly linked to the definition of Felty's syndrome itself [1]. *Rheumatoid arthritis* - **Rheumatoid arthritis** is a prerequisite for diagnosing Felty's syndrome, as it represents the underlying chronic inflammatory disease [1]. - Patients typically have severe, long-standing, and often seropositive rheumatoid arthritis [1]. *Neutropenia* - **Neutropenia** (low neutrophil count) is a hallmark of Felty's syndrome, contributing to an increased risk of infections [1]. - The neutropenia is often accompanied by active rheumatoid arthritis and splenomegaly [1]. *Splenomegaly* - **Splenomegaly** (enlarged spleen) is the third essential component of the classic triad in Felty's syndrome [1]. - The enlarged spleen is thought to contribute to the neutropenia by sequestering or destroying neutrophils [1].

Question 1

Joint not involved in RA ?

Accepted Answer

DIP

Answer

PIP

Answer

Wrist

Answer

MCP

Question 2

Palpable purpura is seen in all conditions except

Accepted Answer

Giant cell arteritis

Answer

Cryoglobulinuria

Answer

H. S. Purpura

Answer

Drug induced vasculitis

Question 3

BASDAI criteria is indicated in

Accepted Answer

Ankylosing spondylitis

Answer

Any autoimmune disease

Answer

Kawasaki Disease

Answer

Rheumatoid Arthritis

Question 4

Which of the following statements regarding Rheumatoid arthritis is false?

Accepted Answer

Pulmonary nodules are present

Answer

Juxta articular osteoporosis may be present

Answer

None of the above

Answer

It is symmetrical involving small and large joints

Question 5

A young man back from leisure trip has swollen knee joints & foreign body sensation in eyes. Likely cause is -

Accepted Answer

Reiter's syndrome

Answer

Behcet's disease

Answer

SLE

Answer

Sarcoidosis

Question 6

Which of the following is seen in Rheumatoid Arthritis?

Accepted Answer

All of the above

Answer

Presence of Rheumatoid Factor (RF)

Answer

Presence of Anti-CCP antibodies

Answer

Higher risk of extra-articular manifestations

Question 7

A 24-year-old woman presents with abdominal pain, joint discomfort, and lower limb rash. She was well until 1 week before presentation. On examination, she has a palpable purpuric rash on her legs, nonspecific abdominal discomfort, and no active joints. She has 3+ proteinuria, normal WBC, no eosinophils, and elevated creatinine of 1.6 mg/dL. Biopsy of the rash confirms vasculitis with immunoglobulin A (IgA) 3+and C3 (complement 3) deposition on immunofluorescence.For the above patient with vasculitis syndrome, select the most likely diagnosis.

Accepted Answer

Henoch-Schonlein purpura

Answer

vasculitis associated with infectious diseases

Answer

Churg-Strauss disease

Answer

polyarteritis nodosa (PAN)

Question 8

Which maternal antibody is responsible for heart block in a baby born to a mother suffering from SLE?

Accepted Answer

Anti-Ro antibody

Answer

Anti-Sm antibody

Answer

Anti-RNP antibody

Answer

Anti-dsDNA antibody

Question 9

Most common presentation of cardiac lupus ?

Accepted Answer

Pericarditis

Answer

Aortic regurgitation

Answer

Libman sacks endocarditis

Answer

Myocarditis

Question 10

True regarding felty's syndrome is all, except -

Accepted Answer

Nephropathy

Answer

Rheumatoid arthritis

Answer

Neutropenia

Answer

Splenomegaly

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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