Rheumatology and Immunology Practice Questions

Q: In a middle aged male having back pain, syndesmophytes involving4 continous vertebrae are seen on Xray. The patient has -

Ankylosing spondylitis. ***Ankylosing spondylitis*** - The presence of **syndesmophytes** involving four continuous vertebrae on X-ray is virtually pathognomonic for **ankylosing spondylitis**, especially in a middle-aged male with back pain. - **Syndesmophytes** in ankylosing spondylitis are typically **thin, vertical bone outgrowths** arising from the annulus fibrosus, leading to the characteristic "bamboo spine" appearance when extensive. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** primarily affects peripheral synovial joints and does not typically cause **syndesmophytes** in the spine. - Spinal involvement in RA usually manifests as **atlantoaxial subluxation** due to inflammation of ligaments in the cervical spine, not extensive syndesmophyte formation. *DISH* - **Diffuse idiopathic skeletal hyperostosis (DISH)**, also known as Forestier's disease, is characterized by widespread ossification of ligaments and entheses, particularly along the anterolateral aspects of the spine. - Unlike syndesmophytes in ankylosing spondylitis, the bony bridges in DISH are typically **flowy and thicker**, often preserving the disc spaces, and do not arise from the annulus fibrosus in the same way. *Osteoarthritis* - **Osteoarthritis** of the spine (spondylosis) is characterized by **osteophytes** (bone spurs) which are typically horizontal and arise from the vertebral body endplates. - **Osteophytes** in osteoarthritis are distinct from the vertical **syndesmophytes** seen in spondyloarthropathies like ankylosing spondylitis and do not bridge multiple vertebral bodies in the same manner.

Q: In gout tophi are not seen in?

Muscles. ***Muscles*** - **Muscles** are not a typical site for the formation of **tophi** in gout because they have a rich blood supply and are constantly undergoing metabolic activity, aiding in the clearance of uric acid crystals. - Tophaceous deposits primarily occur in tissues with **poor vascularity** and lower temperatures, where uric acid crystals can more easily precipitate and accumulate. *Nasal cartilage* - **Cartilage**, including the **nasal cartilage**, is a common site for tophi due to its **avascular** nature, which allows for easier deposition of **uric acid crystals** [1]. - Tophi in cartilage can manifest as painless or tender nodules. *Skin* - **Skin**, especially around joints or on the ear helix, is a frequent location for **tophi** formation, appearing as subcutaneous nodules [1]. - These deposits are often visible through the skin and can ulcerate if left untreated [1]. *Synovium* - The **synovium** is a primary target of gout, with **uric acid crystal deposition** leading to inflammatory arthritis [2]. - While acute inflammation involves the release of crystals into the synovial fluid, persistent high urate levels can lead to **tophaceous deposits** within the synovial membrane itself, contributing to chronic joint damage [1].

Q: Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Angioneurotic edema. ***Angioneurotic edema*** - The rapid onset of **laryngeal edema**, **stridor**, **hoarseness**, and **tongue swelling** following peanut consumption points to an allergic reaction, specifically **anaphylaxis** causing angioedema [1], [2]. - This is a life-threatening condition due to potential **airway obstruction**. *Foreign body bronchus* - While a foreign body could cause **stridor** if large enough to impact the trachea, symptoms like **laryngeal edema** and **tongue swelling** are not typical. - It usually presents with sudden coughing, wheezing, and possibly dyspnea, often without rapid-onset, diffuse swelling. *Foreign body larynx* - A foreign body in the larynx might cause hoarseness and stridor, but **laryngeal edema** and **tongue swelling** are not primary features of a simple foreign body obstruction. - The history of peanut ingestion and rapid systemic inflammatory response makes an allergic reaction more likely [2]. *Pharyngeal abscess* - A pharyngeal abscess typically develops more slowly, with symptoms including **severe sore throat**, **fever**, and **difficulty swallowing**. - It would not usually present with the rapid onset of severe **laryngeal edema** and **tongue swelling** immediately after peanut consumption.

Q: Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Libman-Sacks endocarditis. ***Libman-Sacks endocarditis*** - Libman-Sacks endocarditis is a **non-infectious valvular vegetation** that is highly characteristic of **systemic lupus erythematosus (SLE)** [3]. - These vegetations can lead to **valvular incompetence** or **stenosis**, primarily affecting the **mitral and aortic valves** [1]. *Mitral valve prolapse* - While mitral valve prolapse can occur in SLE patients, it is a relatively common condition in the general population and is **not as specifically linked** to SLE pathology as Libman-Sacks endocarditis. - It involves the **leaflet(s) of the mitral valve bulging** back into the left atrium during systole, which causes a **mid-systolic click and late systolic murmur**, but does not represent the specific immune-mediated damage seen in SLE. *Hemorrhagic pericarditis* - Pericarditis is a common cardiac manifestation in SLE, leading to **inflammation of the pericardium**, but it is typically **serous or fibrinous**, not usually hemorrhagic. - **Hemorrhagic pericarditis** is more often associated with conditions like malignancy, tuberculosis, or trauma, and is not a typical presentation of SLE. *Infective endocarditis* - **Infective endocarditis** is caused by microbial infection of the heart valves, resulting in **vegetations containing bacteria or fungi** [2]. - While SLE patients can be at increased risk for infections due to immunosuppression, the vegetations of Libman-Sacks endocarditis are **sterile (non-infectious)** and distinct in their underlying pathophysiology [1].

Q: All are true regarding Ankylosing spondylitis except -

More common in females. ***More common in females*** - **Ankylosing spondylitis** (AS) is **more common in males** than females, with a male-to-female ratio typically ranging from 2:1 to 3:1. - While females can be affected, their disease presentation might be milder and diagnosis often delayed. *Sacroilitis* - **Sacroiliitis** is a hallmark feature and often the **earliest radiographic finding** in ankylosing spondylitis, characterized by inflammation of the sacroiliac joints [1]. - It is crucial for the diagnosis of AS, causing **buttock pain** and stiffness [1]. *HLA -B27* - The presence of the **HLA-B27** allele is strongly associated with ankylosing spondylitis, found in **90-95% of Caucasian patients** with AS [1]. - While not diagnostic on its own, it significantly increases the risk and supports the diagnosis in conjunction with clinical and imaging findings [1]. *Iridocyclitis* - **Acute anterior uveitis (iritis or iridocyclitis)** is a common **extra-articular manifestation** of ankylosing spondylitis, affecting approximately 25-40% of patients [1]. - It presents with **eye pain**, redness, and photophobia, and can precede or follow the onset of joint symptoms.

Q: TRUE about arthropathy in hemochromatosis:

It usually occurs after age 50. ***It usually occurs after age 50*** - Hemochromatosis-related arthropathy typically manifests later in life, commonly **after the age of 50**, aligning with the progressive accumulation of iron. - The chronicity of iron overload is necessary for significant joint damage to occur, leading to symptoms in older individuals.*Acute brief attacks usually affects shoulder joints* - Arthropathy in hemochromatosis is generally a **chronic, progressive condition**, not characterized by acute, brief attacks. - While various joints can be affected, the **second and third metacarpophalangeal (MCP) joints** are characteristically the first and most commonly involved, not usually the shoulder.*Lower limb joints are first affected* - The **second and third metacarpophalangeal (MCP) joints** of the hands are classic initial sites of involvement in hemochromatosis arthropathy [1]. - Involvement of lower limb joints, such as the knees and hips, typically occurs later in the disease course.*Arthropathy improves with phlebotomy* - While phlebotomy is crucial for removing excess iron and preventing further organ damage in hemochromatosis, it generally **does not reverse or significantly improve existing arthropathy**. - Joint damage due to iron deposition and subsequent cartilage destruction is often irreversible once established, though phlebotomy can prevent worsening of joint symptoms.

Q: Which of the following is true about psoriatic arthritis

All of the options. ***All of the options*** - **Psoriatic arthritis** is a seronegative spondyloarthropathy [2] that can manifest with a wide range of joint involvement, including **sacroiliitis**, characteristic radiological changes like **pencil-in-cup deformity**, and involvement of both **distal** and **proximal interphalangeal joints** [1]. *Sacroiliitis is a common feature* - **Sacroiliitis** occurs in approximately 20-40% of patients with psoriatic arthritis, contributing to inflammatory back pain. - It is often **asymmetrical** and can be detected radiographically [1], distinguishing it from the typically symmetrical sacroiliitis of ankylosing spondylitis. *Pencil in cup deformity is a radiological finding* - This characteristic radiological finding, known as **arthritis mutilans**, is seen in a severe subtype of psoriatic arthritis where there is **osteolysis** of the phalanx and telescoping of the digit [2]. - It results from severe bone erosion at the joint margins, creating a "pencil-in-cup" appearance. *Involves distal joints of hand and foot and proximal interphalangeal joints* - **DIP joint involvement** (distal interphalangeal) is a classic feature of psoriatic arthritis, distinguishing it from rheumatoid arthritis [1], [2]. - Involvement of the **PIP joints** (proximal interphalangeal) and other peripheral joints is also common [1], along with **dactylitis** (sausage digits) and **enthesitis**.

Q: Bechterew disease is?

Ankylosing spondylitis. ***Ankylosing spondylitis*** - **Bechterew disease** is an older term sometimes used to refer to **ankylosing spondylitis**. [1] - It is a chronic inflammatory disease primarily affecting the **axial skeleton**, including the spine and sacroiliac joints. [1] *Beh''et''s disease* - This is a separate chronic, systemic inflammatory disease characterized by **recurrent oral and genital ulcers**, **skin lesions**, and **ocular involvement**. - It does not primarily affect the spine in the same way as ankylosing spondylitis and is not known as Bechterew disease. *Sjogren''s syndrome* - This is an **autoimmune disease** primarily characterized by **dry eyes** (**xerophthalmia**) and **dry mouth** (**xerostomia**) due to lymphocytic infiltration of exocrine glands. - It is not referred to as Bechterew disease and has distinct clinical features from ankylosing spondylitis. *Psoriasis* - This is a chronic **autoimmune skin condition** characterized by red, scaly patches on the skin, often associated with **psoriatic arthritis**. [1] - While psoriatic arthritis can involve the spine, psoriasis itself is a skin condition and is not synonymous with Bechterew disease. [1]

Q: Behcet's syndrome is characterized by all, Except:

Myocarditis. ***Myocarditis*** - While Behcet's syndrome can affect various organ systems, **cardiac involvement** in the form of myocarditis is **rare** and not a characteristic feature. - Cardiac manifestations are more commonly pericarditis or intracardiac thrombi, not primarily inflammation of the heart muscle itself. *Erythema Nodosum* - **Erythema nodosum** is a common mucocutaneous manifestation of Behcet's syndrome, characterized by **tender, erythematous nodules** typically on the shins. - It is part of the diagnostic criteria and reflects the systemic inflammatory nature of the disease. *Thrombophlebitis* - **Thrombophlebitis**, particularly **venous thrombosis**, is a hallmark feature of Behcet's syndrome due to its characteristic **hypercoagulable state**. - This can affect both superficial and deep veins, sometimes leading to life-threatening complications. *Oral and Genital ulcers* - **Recurrent oral aphthous ulcers** are the **most common and often the first symptom** of Behcet's syndrome, a mandatory criterion for diagnosis. - **Genital ulcers**, specifically aphthous lesions on the scrotum or labia, are also very common and contribute significantly to the diagnostic criteria.

Q: Seronegative spondarthritides includes all EXCEPT

Rheumatoid arthritis. ***Rheumatoid arthritis*** - Rheumatoid arthritis (RA) is characterized by the presence of **rheumatoid factor (RF)** and/or **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, making it a **seropositive** arthropathy. [1] - While it causes an inflammatory arthritis, its serological markers differentiate it from the seronegative spondyloarthropathies. *Reiter's syndrome* - Reiter's syndrome, now commonly referred to as **reactive arthritis**, is a classic example of a seronegative spondyloarthropathy. [1] - It is often triggered by an infection and is typically **RF-negative** and **HLA-B27 positive**. *Ankylosing spondylitis* - **Ankylosing spondylitis (AS)** is a prototypical seronegative spondyloarthropathy, characterized by inflammation primarily affecting the **spine and sacroiliaciac joints**. [1] - It is defined by the **absence of RF** and **anti-CCP antibodies**, though it is strongly associated with **HLA-B27**. *Psoriatic arthritis* - **Psoriatic arthritis (PsA)** is another member of the seronegative spondyloarthropathies, occurring in individuals with **psoriasis**. [1] - Like other conditions in this group, patients with PsA are typically **negative for RF** and **anti-CCP antibodies**.

Question 1

In a middle aged male having back pain, syndesmophytes involving4 continous vertebrae are seen on Xray. The patient has -

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

DISH

Answer

Osteoarthritis

Question 2

In gout tophi are not seen in?

Accepted Answer

Muscles

Answer

Nasal cartilage

Answer

Skin

Answer

Synovium

Question 3

Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

Accepted Answer

Angioneurotic edema

Answer

Foreign body bronchus

Answer

Foreign body larynx

Answer

Pharyngeal abscess

Question 4

Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

Accepted Answer

Libman-Sacks endocarditis

Answer

Mitral valve prolapse

Answer

Hemorrhagic pericarditis

Answer

Infective endocarditis

Question 5

All are true regarding Ankylosing spondylitis except -

Accepted Answer

More common in females

Answer

Sacroilitis

Answer

HLA -B27

Answer

Iridocyclitis

Question 6

TRUE about arthropathy in hemochromatosis:

Accepted Answer

It usually occurs after age 50

Answer

Acute brief attacks usually affects shoulder joints

Answer

Lower limb joints are first affected

Answer

Arthropathy improves with phlebotomy

Question 7

Which of the following is true about psoriatic arthritis

Accepted Answer

All of the options

Answer

Sacroiliitis is a common feature

Answer

Pencil in cup deformity is a radiological finding

Answer

Involves distal joints of hand and foot and proximal interphalangeal joints

Question 8

Bechterew disease is?

Accepted Answer

Ankylosing spondylitis

Answer

Behçet's disease

Answer

Sjogren's syndrome

Answer

Psoriasis

Question 9

Behcet's syndrome is characterized by all, Except:

Accepted Answer

Myocarditis

Answer

Erythema Nodosum

Answer

Thrombophlebitis

Answer

Oral and Genital ulcers

Question 10

Seronegative spondarthritides includes all EXCEPT

Accepted Answer

Rheumatoid arthritis

Answer

Reiter's syndrome

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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