Rheumatology and Immunology Practice Questions

Q: Which of the following is not associated with ankylosing spondylitis?

SLE. ***SLE*** - **Systemic lupus erythematosus (SLE)** is a systemic autoimmune disease characterized by a wide range of autoantibodies and multi-organ involvement, distinct from the primarily axial skeletal inflammation seen in ankylosing spondylitis. [1] - While both are autoimmune conditions, they have different genetic predispositions, clinical manifestations, and pathogenic mechanisms; **HLA-B27** is strongly associated with ankylosing spondylitis, whereas SLE is not. [1] *Reiter's syndrome* - **Reiter's syndrome**, now known as reactive arthritis, is a **seronegative spondyloarthropathy** that shares many features with ankylosing spondylitis, including **HLA-B27 association** and spinal involvement. [1] - It often follows a genitourinary or gastrointestinal infection and can present with **arthritis**, **urethritis**, and **conjunctivitis**, similar to other related spondyloarthropathies. [1] *Crohn's disease* - **Crohn's disease** is a type of inflammatory bowel disease (IBD) that has a well-established association with **spondyloarthropathies**, including ankylosing spondylitis. [1] - Approximately 5-10% of patients with Crohn's disease develop axial skeleton involvement, and both conditions share genetic predispositions, including **HLA-B27**. [1] *Psoriatic arthropathy* - **Psoriatic arthropathy** (also called psoriatic arthritis) is another **seronegative spondyloarthropathy** that frequently presents with axial skeleton involvement, similar to ankylosing spondylitis. [1] - It is closely linked to **psoriasis** and can manifest in various patterns including symmetrical polyarthritis, oligoarthritis, and sacroiliitis, often sharing common inflammatory pathways with ankylosing spondylitis. [1]

Q: A 24-year-old female presents with abdominal pain, hematuria, and arthralgia. On examination, a palpable purpuric rash is seen on the trunk, limbs, and buttocks. Coagulation tests are normal. What is the most probable diagnosis?

Henoch-Schonlein purpura. ***Henoch-Schonlein purpura*** - The classic tetrad of **palpable purpura**, **abdominal pain**, **arthralgia**, and **renal involvement (hematuria)** is highly characteristic of Henoch-Schonlein Purpura (HSP) [1]. - Normal coagulation tests differentiate HSP from other coagulopathies, as it is a **leukocytoclastic vasculitis** mediated by IgA immune complexes [1]. *Hemolytic uremic syndrome* - This syndrome is characterized by a triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury** [1]. - While it involves renal symptoms (hematuria), the presence of **palpable purpura** and **arthralgia** alongside normal coagulation tests makes HSP more likely. *Meningococcemia* - Typically presents with a **rapidly progressive non-blanching petechial or purpuric rash**, often associated with **fever**, **meningitis**, and **septic shock**. - Although it causes purpura, the patient does not exhibit signs of severe sepsis or meningitis; the specific constellation of abdominal pain, arthralgia, and hematuria points away from this diagnosis. *Thrombotic thrombocytopenic purpura* - Characterized by a pentad of **fever**, **thrombocytopenia**, **microangiopathic hemolytic anemia**, **neurological symptoms**, and **renal impairment** [1]. - While purpura can occur due to thrombocytopenia, the purpura is generally non-palpable, and the normal coagulation tests and lack of severe anemia make this less likely.

Q: All of the following are true about Rheumatoid Arthritis, except which of the following?

HLA-B27 is a marker for rheumatoid arthritis.. ***HLA-B27 is a marker for rheumatoid arthritis.*** - **HLA-B27** is a strong genetic marker primarily associated with **spondyloarthropathies**, such as **ankylosing spondylitis** and **reactive arthritis**, not rheumatoid arthritis [1]. - While it indicates a genetic predisposition to certain rheumatological conditions, it is not linked to the pathogenesis or diagnosis of rheumatoid arthritis. *HLA-DR determine genetic susceptibility* - **HLA-DR alleles**, particularly **HLA-DR4** and **HLA-DR1**, are strongly associated with genetic susceptibility to **rheumatoid arthritis** and often predict more severe disease. - These genes play a crucial role in antigen presentation to T-cells, contributing to the autoimmune response seen in RA. *Anemia* - **Anemia of chronic disease** is a common complication in patients with **rheumatoid arthritis**, often characterized by normal or elevated iron stores and reduced iron utilization [1]. - Inflammatory cytokines, such as **IL-6**, contribute to this type of anemia by affecting erythropoiesis and iron metabolism [1]. *Subcutaneous nodules* - **Subcutaneous nodules**, also known as **rheumatoid nodules**, are characteristic extra-articular manifestations of **rheumatoid arthritis**, typically found on extensor surfaces, such as the elbows or hands [1]. - These nodules are associated with more severe disease and are usually painless [1].

Q: Which condition is primarily associated with the presence of ANCA (Anti-Neutrophil Cytoplasmic Antibodies)?

Granulomatosis with Polyangiitis (GPA). ***Wegener's granulomatosis*** - ANCA (Antineutrophil cytoplasmic antibodies) are highly associated with Wegener's granulomatosis, manifesting as **granulomatous inflammation** of the lungs and kidneys. - Patients often have a positive **c-ANCA** with anti-PR3 antibodies, correlating with disease activity. *Goodpasture syndrome* - Primarily associated with **anti-glomerular basement membrane** antibodies affecting the kidneys and lungs, not ANCA. - Symptoms typically include **hemoptysis** and **renal failure**, distinguishing it from ANCA-associated vasculitides. *Henoch-Schonlein Purpura* - Characterized by **IgA vasculitis** leading to symptoms like purpura, abdominal pain, and renal involvement, but is not associated with ANCA. - Diagnosis relies on **skin biopsy** showing IgA deposits, contrasting with the ANCA profile in Wegener's. *Rheumatoid arthritis* - An autoimmune condition mainly involving **rheumatoid factor (RF)** [1] and anti-CCP antibodies, rather than ANCA. - Affects joints symmetrically and is marked by morning stiffness, which differs from the systemic vasculitis seen in ANCA-positive diseases.

Q: Pleural effusion in rheumatoid arthritis is typically associated with the following features, except:

Glucose > 60 mg/dl. ***Glucose > 60 mg/dl*** - Pleural effusions in rheumatoid arthritis are classically characterized by **very low glucose levels** (often 3 gm/dl* - Rheumatoid pleural effusions are almost always **exudative**, meaning they have a high protein content, typically above 3 g/dL. [1] - This is due to increased vascular permeability and leakage of proteins into the pleural space from inflammation associated with RA. *Pleural fluid protein to serum protein ratio of >0.5* - An exudative effusion, characteristic of rheumatoid arthritis, is defined by a pleural fluid protein to serum protein ratio of **greater than 0.5**. [1] - This ratio indicates a significant protein leak into the pleural space, reflecting inflammation rather than just hydrostatic pressure changes. *Pleural fluid LDH to serum LDH ratio of >0.6* - Similar to protein, rheumatoid pleural effusions are exudative and exhibit a high pleural fluid LDH to serum LDH ratio, typically **greater than 0.6**. [1] - Elevated LDH in the pleural fluid reflects cellular breakdown and inflammation within the pleural space.

Q: Which of the following is not typically associated with Reiter's syndrome?

Subcutaneous nodules. ***Subcutaneous nodules*** - **Subcutaneous nodules** are characteristic of conditions like **rheumatoid arthritis** [1] and **rheumatic fever**, not Reiter's syndrome (reactive arthritis). - While Reiter's syndrome can present with a variety of extra-articular manifestations, these specific nodules are not part of its typical clinical picture. *Oral ulcers* - **Oral ulcers** (painless aphthous ulcers) are a known mucocutaneous manifestation that can occur in patients with Reiter's syndrome [2]. - They are one of the 'can't see, can't pee, can't climb a tree' symptoms often associated with the condition, though less common than arthritis. *Keratoderma blenorrhagicum* - **Keratoderma blenorrhagicum** is a specific skin lesion characterized by hyperkeratotic, waxy, yellow-brown papules and plaques, predominantly on the palms and soles [2]. - It is highly characteristic, though not universally present, in patients with Reiter's syndrome and is clinically and histologically indistinguishable from pustular psoriasis. *Circinate balanitis* - **Circinate balanitis** is a painless inflammation of the glans penis characterized by shallow, serpiginous erosions [2]. - It is a common mucocutaneous manifestation of Reiter's syndrome, particularly in uncircumcised males [2].

Q: Which is the rheumatoid arthritis autoantibody?

Anti CCP. ***Anti CCP*** - **Anti-Citrullinated Protein Antibodies (CCP)** are highly specific for **rheumatoid arthritis** and are used for diagnosing this condition. - A positive **Anti-CCP** test can indicate the presence of **rheumatoid arthritis** even before clinical symptoms appear. *Anti histone* - This antibody is primarily associated with **drug-induced lupus erythematosus**, not rheumatoid arthritis. - It identifies a **response** to medications, rather than being a specific marker for a rheumatic condition like RA. *Anti DLE* - Suggests antibodies related to **discoid lupus erythematosus**, not rheumatoid arthritis. - These antibodies do not correlate with inflammatory joint disease or diagnosis of RA. *Anti ds DNA* - Commonly associated with **systemic lupus erythematosus** (SLE) rather than rheumatoid arthritis [1]. - While relevant for lupus, it lacks specificity for diagnosing rheumatic arthritis; ANA testing is noted as not useful in diagnosing RA specifically [1].

Q: Which of the following conditions is least likely to present with polyarticular involvement in clinical practice?

Gout. ***Gout*** - Classically presents as **monoarticular arthritis**, affecting a single joint (typically the **first metatarsophalangeal joint** in 85-90% of acute attacks). - While chronic **tophaceous gout** can involve multiple joints, acute presentations are predominantly **monoarticular**, making it the least likely to present with polyarticular involvement. *Psoriatic arthritis* - Often presents with **symmetric polyarthritis** pattern similar to rheumatoid arthritis, involving multiple small and large joints. - Can also manifest as **oligoarthritis** or **spondyloarthritis**, but polyarticular involvement is common in established disease. *SLE* - Presents with **polyarthritis** in approximately **90% of patients**, typically affecting small joints of hands, wrists, and knees symmetrically. - Joint involvement is one of the most common manifestations and is included in **SLE classification criteria** due to its frequent occurrence. *Ankylosing spondylitis* - Primarily affects the **axial skeleton** (spine and sacroiliac joints) in a polyarticular pattern, causing progressive spinal fusion. - Can also involve **peripheral joints** (hips, shoulders, knees) in addition to spinal involvement, representing polyarticular disease.

Q: Most common pulmonary manifestation of SLE is which of the following?

Pleuritis. ***Pleuritis*** - **Pleuritis** and **pleural effusions** are the most common pulmonary manifestations in patients with SLE, affecting up to 50% of patients [1]. - They often present with **pleuritic chest pain** and can be diagnosed via chest X-ray or CT scan [1]. *Shrinking Lung* - **Shrinking lung syndrome** is a rare but severe manifestation characterized by decreased lung volumes and an elevated diaphragm, but it is not the most common [1]. - Its pathogenesis is unclear, but it may involve phrenic neuropathy, diaphragmatic myopathy, or chronic pleuritis with fibrosis [1]. *Intra alveolar hemorrhage* - **Diffuse alveolar hemorrhage** is a life-threatening complication of SLE, leading to acute respiratory failure and hemoptysis, but it is uncommon [1]. - It often requires aggressive immunosuppressive therapy due to its high mortality rate [1]. *Interstitial inflammation* - **Interstitial lung disease** (ILD) in SLE, manifesting as interstitial inflammation or fibrosis, is a less common pulmonary complication compared to pleuritis [1]. - While it can lead to progressive dyspnea and cough, it usually develops in a chronic course [1].

Q: Bilateral hilar lymphadenopathy, along with non-caseating granulomas, is a characteristic feature of:

Sarcoidosis. ***Sarcoidosis*** - This autoimmune disease is characterized by the formation of **non-caseating granulomas** in various organs, most commonly the lungs and lymphatic system. - **Bilateral hilar lymphadenopathy** is a classic radiographic finding, seen in up to 90% of cases, often accompanied by interstitial lung disease [1]. *Scleroderma* - Characterized by **fibrosis** of the skin and internal organs, leading to hardening and thickening of tissues. - Does not typically present with bilateral hilar lymphadenopathy or non-caseating granulomas. *SLE* - An autoimmune disease characterized by a wide array of symptoms affecting multiple organ systems, including arthritis, skin rashes, and kidney problems. - While it can manifest with lung involvement, such as pleuritis or interstitial lung disease, it does not typically involve **non-caseating granulomas** or classic hilar lymphadenopathy. *Stein-Leventhal syndrome* - Also known as **polycystic ovary syndrome (PCOS)**, it is an endocrine disorder characterized by hormonal imbalances, irregular periods, and androgen excess. - This syndrome is entirely unrelated to bilateral hilar lymphadenopathy or the formation of granulomas.

Question 1

Which of the following is not associated with ankylosing spondylitis?

Accepted Answer

SLE

Answer

Reiter's syndrome

Answer

Crohn's disease

Answer

Psoriatic arthropathy

Question 2

A 24-year-old female presents with abdominal pain, hematuria, and arthralgia. On examination, a palpable purpuric rash is seen on the trunk, limbs, and buttocks. Coagulation tests are normal. What is the most probable diagnosis?

Accepted Answer

Henoch-Schonlein purpura

Answer

Hemolytic uremic syndrome

Answer

Meningococcemia

Answer

Thrombotic thrombocytopenic purpura

Question 3

All of the following are true about Rheumatoid Arthritis, except which of the following?

Accepted Answer

HLA-B27 is a marker for rheumatoid arthritis.

Answer

Anemia

Answer

Subcutaneous nodules

Answer

HLA-DR determine genetic susceptibility

Question 4

Which condition is primarily associated with the presence of ANCA (Anti-Neutrophil Cytoplasmic Antibodies)?

Accepted Answer

Granulomatosis with Polyangiitis (GPA)

Answer

Henoch-Schonlein Purpura

Answer

Rheumatoid arthritis

Answer

Goodpasture syndrome

Question 5

Pleural effusion in rheumatoid arthritis is typically associated with the following features, except:

Accepted Answer

Glucose > 60 mg/dl

Answer

Protein > 3 gm/dl

Answer

Pleural fluid protein to serum protein ratio of >0.5

Answer

Pleural fluid LDH to serum LDH ratio of >0.6

Question 6

Which of the following is not typically associated with Reiter's syndrome?

Accepted Answer

Subcutaneous nodules

Answer

Circinate balanitis

Answer

Oral ulcers

Answer

Keratoderma blenorrhagicum

Question 7

Which is the rheumatoid arthritis autoantibody?

Accepted Answer

Anti CCP

Answer

Anti DLE

Answer

Anti ds DNA

Answer

Anti histone

Question 8

Which of the following conditions is least likely to present with polyarticular involvement in clinical practice?

Accepted Answer

Gout

Answer

Psoriatic arthritis

Answer

SLE

Answer

Ankylosing spondylitis

Question 9

Most common pulmonary manifestation of SLE is which of the following?

Accepted Answer

Pleuritis

Answer

Shrinking Lung

Answer

Interstitial inflammation

Answer

Intra alveolar hemorrhage

Question 10

Bilateral hilar lymphadenopathy, along with non-caseating granulomas, is a characteristic feature of:

Accepted Answer

Sarcoidosis

Answer

Scleroderma

Answer

SLE

Answer

Stein-leventhal syndrome

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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