Rheumatology and Immunology Practice Questions

Q: Which arthritis is commonly associated with uveitis?

Ankylosing spondylitis. **Ankylosing spondylitis** - **Uveitis** is a common **extra-articular manifestation** of ankylosing spondylitis, occurring in up to 40% of patients. [1] - It typically presents as acute **anterior uveitis**, causing eye pain, redness, and photophobia. *Reiter's disease* - Also known as **reactive arthritis**, Reiter's disease is associated with **conjunctivitis** or **uveitis**, but ankylosing spondylitis has a higher prevalence of uveitis as a defining feature. [1] - Reiter's disease classically presents with the triad of **arthritis**, **urethritis**, and **conjunctivitis** (can't see, can't pee, can't climb a tree). [2] *Still's disease* - **Still's disease**, or systemic juvenile idiopathic arthritis, can be associated with **chronic anterior uveitis**, particularly in pauciarticular forms. [3] - However, the question asks about uveitis commonly associated with "arthritis" generally, and ankylosing spondylitis has a stronger, more direct association as an extra-articular manifestation. *RA* - **Rheumatoid arthritis** is rarely associated with uveitis. - Ocular manifestations in RA typically include **scleritis** or **episcleritis**, not primarily uveitis.

Q: Poly arteritis nodosa does not involve

Pulmonary artery. ***Pulmonary artery*** - **Polyarteritis nodosa (PAN)** is a systemic necrotizing vasculitis that primarily affects **medium-sized arteries**, but characteristically spares the **pulmonary circulation** [1]. - While other forms of vasculitis can involve the lungs, significant **pulmonary artery** involvement is a key differentiating feature that excludes PAN [1]. *Bronchial artery* - The **bronchial arteries** are medium-sized arteries that supply the bronchi and lung parenchyma. - They can be involved in PAN, leading to symptoms like **hemoptysis** or pleuritic chest pain. *Cerebral artery* - PAN can affect arteries in the central nervous system, including the **cerebral arteries**, leading to neurological symptoms like stroke, seizures, or peripheral neuropathy [1]. - Neurological manifestations are common in PAN and can be severe [1]. *Renal artery* - **Renal artery** involvement is a classic and frequently severe manifestation of PAN, often leading to **hypertension**, renal infarction, and renal failure [1]. - Microaneurysms of the renal arteries are a characteristic angiographic finding.

Q: The common HLA type associated with Behcet disease is _________

HLA B51. ***HLA B51*** - **HLA-B51** is the most common **HLA type strongly associated** with Behçet's disease, particularly in populations of the Silk Road region. - The presence of **HLA-B51** increases susceptibility and may correlate with a more severe disease course, including a higher risk of **ocular involvement**. *HLA DR4* - **HLA-DR4** is a genetic marker primarily associated with diseases like **Rheumatoid Arthritis** and certain types of juvenile idiopathic arthritis, not Behçet's disease. - It plays a role in presenting antigens to T-cells, but its link to Behçet's pathogenesis is not significant. *HLA B27* - **HLA-B27** is strongly associated with **spondyloarthropathies**, such as **ankylosing spondylitis**, reactive arthritis, and psoriatic arthritis, but not Behçet's disease [1]. - Its presence is a key diagnostic indicator for these specific rheumatic conditions [1]. *HLA CW6* - **HLA-Cw6** is primarily associated with **psoriasis vulgarisa**, particularly with early-onset and more severe forms of the condition. - It is not a known genetic marker for susceptibility to Behçet's disease.

Q: A 55-yrs-old woman complains of stiff, aching hands, especially in the morning. Radiographs of the hands reveal expansion at the base of the terminal phalanges & tapering of the proximal phalanges. This patient most likely has:

Psoriatic arthritis. ***Psoriatic arthritis*** - The radiographs showing **expansion at the base of the terminal phalanges** (distal interphalangeal joints, or **DIPs**) and **tapering of the proximal phalanges** (giving a "pencil-in-cup" appearance) are highly characteristic of psoriatic arthritis. - While morning stiffness is common in inflammatory arthritis, the specific radiographic findings, along with potential **dactylitis** (sausage digits) or skin manifestations, point strongly to psoriatic arthritis. *SLE* - **Systemic lupus erythematosus (SLE)** is a systemic autoimmune disease that can cause arthralgia or arthritis, but it typically presents with **non-erosive arthropathy** and does not show the destructive radiographic changes described. - Characteristic features of SLE include malar rash, photosensitivity, serositis, and renal involvement, which are not mentioned. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** primarily affects the **small joints of the hands and feet**, but typically spare the DIP joints. - Radiographic findings in RA include **juxta-articular erosions** and joint space narrowing but do not typically show the "pencil-in-cup" deformity seen in this case. *Gouty arthritis* - **Gouty arthritis** is caused by the deposition of **urate crystals** and typically presents with acute, severe pain, often affecting a single joint (classically the **first metatarsophalangeal joint**). - Radiographic features include **punched-out erosions** with sclerotic borders and overhanging edges, which differ from the description provided.

Q: Vasanti, 28-year-old, presents with complaints of tightness of fingers. There is also history of dysphagia. Which of the following is the probable diagnosis:

Scleroderma. ***Scleroderma*** - **Tightening of fingers** (sclerodactyly) and **dysphagia** are hallmark symptoms of scleroderma, especially the systemic form [1]. - Dysphagia in scleroderma is often due to **esophageal dysmotility** caused by fibrosis. *Rheumatoid arthritis* - Primarily affects the **synovial joints**, leading to pain, swelling, and morning stiffness, but not typically finger tightness or dysphagia as a primary complaint. - While it can affect other organs, **cutaneous fibrosis** and **esophageal dysmotility** are not characteristic features. *Dermatomyositis* - Characterized by **muscle weakness** (especially proximal) and distinctive **skin rashes** (e.g., heliotrope rash, Gottron's papules). - While dysphagia can occur due to muscle involvement, **tightness of fingers** due to skin thickening is not a primary feature. *Polyarteritis nodosa* - A **necrotizing vasculitis** affecting medium-sized arteries, leading to symptoms related to organ ischemia (e.g., kidney, GI, neurological). - It does not typically cause **skin tightening of the fingers** or **dysphagia** as described.

Q: All are true about gout except:

Is directly related to alcohol consumption. *** Is directly related to alcohol consumption*** - While **alcohol consumption**, particularly beer and spirits, is a **risk factor** for gout flares by increasing uric acid production and inhibiting its excretion, it is not the direct cause of the underlying **purine metabolism disorder**. [1], [2] - Gout is primarily caused by **hyperuricemia**, which leads to the deposition of **monosodium urate crystals** in joints and tissues. [3], [4] *Is caused by purine metabolism disorder* - Gout is fundamentally caused by a **disorder of purine metabolism**, leading to either **overproduction of uric acid** or **underexcretion of uric acid** from the kidneys. [1], [2] - This imbalance results in elevated **serum uric acid levels** (hyperuricemia), which is a prerequisite for gout development. [1] *Causes tophi in the extraocular muscle tendon* - Gout can cause **tophi**, which are deposits of **monosodium urate crystals**, but they typically form in cooler peripheral areas like the **ear helix**, fingers, toes, and around joints. [4] - While rare, tophi can occur in unusual locations, deposition in **extraocular muscle tendons** is highly atypical and not a common manifestation of gout. *Causes podagra* - **Podagra** is a classic symptom of gout, referring specifically to acute inflammation and severe pain in the **first metatarsophalangeal joint** (big toe). [2] - It is one of the most common initial presentations of **gouty arthritis** and is highly characteristic of the disease. [2]

Q: A 28-year-old woman with limited cutaneous scleroderma for the past 10 years complains of shortness of breath for the last month. What is the most likely diagnosis?

Interstitial lung disease. ***Interstitial lung disease*** - **Interstitial lung disease (ILD)** is a common and serious complication of **limited cutaneous scleroderma**, often presenting with **progressive shortness of breath** [1]. - Pathologically, it involves **fibrosis** and inflammation of the lung parenchyma, leading to impaired gas exchange [1]. *Pulmonary artery hypertension* - While **pulmonary artery hypertension (PAH)** can occur in scleroderma, it typically presents with more prominent symptoms like **fatigue**, **chest pain**, and **syncope** in later stages. - Though shortness of breath is a symptom, **ILD** is a more direct and common cause in this context, and PAH may follow ILD or occur independently. *Bronchiectasis* - **Bronchiectasis** is characterized by **permanent dilation of the bronchi** and is usually associated with **chronic cough with sputum production**, recurrent infections, and hemoptysis, which are not mentioned here. - It is not a primary lung manifestation of scleroderma, occurring more commonly in conditions like **cystic fibrosis** or severe infections. *Congestive heart failure* - **Congestive heart failure** would likely present with signs of fluid overload such as **peripheral edema**, **jugular venous distention**, and **rales** on lung auscultation, none of which are described. - While scleroderma can affect the heart, **ILD** is a more common and direct pulmonary complication causing shortness of breath.

Q: Following are listed as (SpA) spondyloarthritis features except

Cervical sprain. **Cervical sprain** - A **cervical sprain** is an injury to the ligaments in the neck, typically caused by trauma or sudden movements, and is not a defining characteristic or feature of spondyloarthritis. - Sprains involve the stretching or tearing of soft tissues, whereas spondyloarthritis is a group of **inflammatory conditions** primarily affecting the spine and peripheral joints. *Dactylitis* - **Dactylitis**, or "sausage digits," refers to the **inflammation of an entire digit** (finger or toe) and is a characteristic feature of spondyloarthritis, particularly **psoriatic arthritis** and **reactive arthritis** [1]. - It results from inflammation of both the joints and the tendons within the affected digit [1]. *Enthesitis* - **Enthesitis** is the **inflammation of the entheses**, which are the sites where tendons or ligaments insert into bone [1]. - This is a hallmark feature of spondyloarthritis, commonly seen at sites like the **Achilles tendon insertion** or the plantar fascia [1]. *HLA B27* - **HLA-B27** is a human leukocyte antigen that is strongly associated with spondyloarthritis [1]. - Its presence is a significant genetic marker found in a high percentage of patients with **ankylosing spondylitis** and other forms of spondyloarthritis [1].

Q: Indications for use of cyclophosphamide in SLE are:

Diffuse proliferative glomerulonephritis. Diffuse proliferative glomerulonephritis - **Cyclophosphamide** is a potent immunosuppressant often used in severe manifestations of **systemic lupus erythematosus (SLE)**, particularly **lupus nephritis**. - **Diffuse proliferative glomerulonephritis (class IV lupus nephritis)** is a severe form of kidney involvement in SLE, characterized by significant inflammation and immune complex deposition, for which cyclophosphamide is a first-line treatment due to its ability to induce remission and prevent progression to end-stage renal disease. *Arthritis* - **Arthritis** in SLE is typically managed with less aggressive therapies such as **NSAIDs**, **hydroxychloroquine**, or low-dose **corticosteroids** [1]. - Cyclophosphamide is generally reserved for life-threatening or organ-threatening manifestations due to its significant side effects. *Oral ulcers* - **Oral ulcers** in SLE are usually a mild cutaneous manifestation and are managed with topical treatments, **hydroxychloroquine**, or occasionally low-dose **systemic corticosteroids**. - The use of cyclophosphamide for oral ulcers would be inappropriate given its toxicity profile. *Anti D NA antibody +ive patients* - While **anti-dsDNA antibodies** are characteristic of SLE and often correlate with disease activity, particularly **lupus nephritis**, their presence alone does not indicate the need for cyclophosphamide [2]. - The decision to use cyclophosphamide is based on the presence of severe organ-threatening disease, not solely on antibody positivity.

Question 1

Which arthritis is commonly associated with uveitis?

Accepted Answer

Ankylosing spondylitis

Answer

Reiter's disease

Answer

Still's disease

Answer

RA

Question 2

Poly arteritis nodosa does not involve

Accepted Answer

Pulmonary artery

Answer

Bronchial artery

Answer

Cerebral artery

Answer

Renal artery

Question 3

The common HLA type associated with Behcet disease is _________

Accepted Answer

HLA B51

Answer

HLA DR4

Answer

HLA B27

Answer

HLA CW6

Question 4

A 55-yrs-old woman complains of stiff, aching hands, especially in the morning. Radiographs of the hands reveal expansion at the base of the terminal phalanges & tapering of the proximal phalanges. This patient most likely has:

Accepted Answer

Psoriatic arthritis

Answer

SLE

Answer

Rheumatoid arthritis

Answer

Gouty arthritis

Question 5

Vasanti, 28-year-old, presents with complaints of tightness of fingers. There is also history of dysphagia. Which of the following is the probable diagnosis:

Accepted Answer

Scleroderma

Answer

Rheumatoid arthritis

Answer

Dermatomyositis

Answer

Polyarteritis nodosa

Question 6

Which of the following is true about rheumatic fever

Accepted Answer

Chorea occurs in the absence of other manifestations after prolonged latent period

Answer

90% of the patients with acute rheumatic fever proceed to rheumatic heart disease

Answer

Characteristic manifestation of carditis in previously unaffected individuals is mitral stenosis

Answer

Isolated aortic valve involvement is most common

Question 7

All are true about gout except:

Accepted Answer

Is directly related to alcohol consumption

Answer

Is caused by purine metabolism disorder

Answer

Causes tophi in the extraocular muscle tendon

Answer

Causes podagra

Question 8

A 28-year-old woman with limited cutaneous scleroderma for the past 10 years complains of shortness of breath for the last month. What is the most likely diagnosis?

Accepted Answer

Interstitial lung disease

Answer

Pulmonary artery hypertension

Answer

Bronchiectasis

Answer

Congestive heart failure

Question 9

Following are listed as (SpA) spondyloarthritis features except

Accepted Answer

Cervical sprain

Answer

Dactylitis

Answer

Enthesitis

Answer

HLA B27

Question 10

Indications for use of cyclophosphamide in SLE are:

Accepted Answer

Diffuse proliferative glomerulonephritis

Answer

Arthritis

Answer

Oral ulcers

Answer

Anti D NA antibody +ive patients

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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