Rheumatology Multiple Choice Questions with Explanations

RHEUMATOLOGY SECTION ONE - APPROACH TO RHEUMATOLOGICAL DISORDERS

Question 1.

A 33-year-old woman presents with a malar rash that is exacerbated by sun exposure. She has experienced episodes of myalgia, pleural effusion, pericarditis, and arthralgia without joint deformity over the course of several years. She has a history of hematuria and no history of drug intake prior to the onset of these symptoms. The best screening test for her disease would be: (AI)

1. Antinuclear antibody

2. Anti-ds-DNA antibody

3. Anti-RNP antibody

4. Anti-histone antibody

DISCUSSION:

A malar rash with arthralgia, serositis, and hematuria in a female of childbearing age suggests the possibility of systemic lupus erythematosus (SLE). However, an SLE-like picture may be seen in drug-induced lupus and mixed connective tissue disorder. Antinuclear antibody is the most sensitive test to screen for SLE. Its repeated absence virtually rules out the possibility of SLE. Anti-ds-DNA (and anti-Sm) antibodies have high specificity and are used to confirm the diagnosis of SLE; however, because of their poor sensitivity, they are not used as screening tests. Mixed connective tissue disorder (MCTD) has features of disorders such as rheumatoid arthritis, limited cutaneous scleroderma (skin stiffness, dysphagia), and polymyositis, in addition to those of SLE. Anti-RNP antibodies are detectable in less than half of SLE patients, but high titers of anti-RNP antibodies are diagnostic of MCTD. Anti-histone antibody is seen in drug-induced lupus (which is unlikely, as there is no history drug intake prior to the onset of symptoms).

ANSWER:

The correct answer is “antinuclear antibody.”

REFERENCES:

Rahman A, Isenberg DA. Chapter 19.11.2. Systemic lupus erythematosus and related disorders. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition.

Hahn B. Chapter 319. Systemic lupus erythematosus. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18th edition.

Question 2.

A 40-year-old female, with a known case of asthma for the last four years, presented with a two-month history of numbness in the right upper and both lower limbs. Examination revealed asymmetric neuropathy and palpable purpura over the lower limbs. Investigations revealed eosinophilia. What is the likely diagnosis? (PGI)

1. Systemic lupus erythematosus (SLE)

2. Polyarteritis nodosa (PAN)

3. Giant cell arteritis (GCA)

4. Churg-Strauss syndrome

DISCUSSION:

Peripheral neuropathy is broadly divided into mononeuritis simplex, mononeuritis multiplex, and polyneuropathy. This patient has asymmetric neuropathy or mononeuritis multiplex. Common causes of mononeuritis multiplex are vasculitic syndromes, infectious diseases such as HIV or leprosy, and other conditions such as diabetes. A vasculitic neuropathy (palpable purpura) with asthma and eosinophilia favors the diagnosis of Churg-Strauss syndrome. Asthma and eosinophilia are not seen in conditions such as SLE, GCA, or PAN.

ANSWER:

The correct answer is “Churg-Strauss syndrome.”

REFERENCES:

Langford CA, Fauci AS. Chapter 326. The Vasculitis Syndromes. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18th edition.

Wells AU, M. du Bois R. Chapter 18.11.5. The lung in vasculitis. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition.

Question 3.

A five-year-old girl presents with fever and conjunctivitis. Physical examination is significant for oral erythema and fissuring along with a generalized maculopapular rash and cervical lymphadenopathy. What is the most likely diagnosis? (UPSC)

1. Henoch-Schonlein purpura

2. Polyarteritis nodosa

3. Kawasaki disease

4. Takayasu’s arteritis

DISCUSSION:

Symptoms of vasculitis vary greatly and depend upon the organs affected and the severity of the disease. The involvement of large vessels (giant cell arteritis, Takayasu’s disease) frequently results in limb claudication, asymmetric blood pressure in the limbs, and the absence of pulses. The involvement of medium vessels (polyarteritis nodosa, Kawasaki disease) results in cutaneous nodules, livedo reticularis, microaneurysms, and mononeuritis multiplex. The involvement of small vessels (ANCA-associated vasculitis, Henoch-Schonlein purpura) results in glomerulonephritis, purpura, and alveolar hemorrhage. Kawasaki disease often begins with fever that is not very responsive to paracetamol. Bilateral conjunctival injection usually begins shortly after the onset of fever. It is not purulent, and it is not painful. Oral manifestations of this disease include erythematous and swollen lips and “strawberry tongue.” Cervical lymphadenopathy is seen in about three-fourths of patients, which are usually non-tender and non-suppurative. Henoch-Schonlein purpura presents with abdominal pain, rashes, palpable purpura, and arthritis. Polyarteritis nodosa and Takayasu’s arteritis have distinct presentations and are unlikely at this age.

ANSWER:

The correct answer is “Kawasaki disease.”

REFERENCES:

Langford CA, Fauci AS. Chapter 326. The Vasculitis Syndromes. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18th edition.

Kawasaki T (1967). "Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children". Arerugi 16 (3): 178–222.

Question 4.

A 45-year-old female complains of pain and swelling in both wrists and knees for three months. There is increased stiffness in the hands early in the morning, which lasts close to 40 minutes. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. What is the most likely diagnosis in this patient? (AIIMS)

1. Rheumatoid arthritis

2. Polymyalgia rheumatica

3. Gouty arthritis

4. Osteoarthritis

DISCUSSION:

Among articular disorders, gout and the spondyloarthropathies are more common in men, whereas rheumatoid arthritis and lupus are more frequent in women. This female patient has symmetrical arthritis with early morning stiffness and involvement of the wrist and metacarpophalangeal joints. All of them are characteristic features of rheumatoid arthritis. Osteoarthritis is seen in elderly patients and is non-inflammatory arthritis. Gout is common in males or postmenopausal females. Its most common presentation is acute mono-articular arthritis, frequently involving the first metatarsophalangeal joint. Swelling and tenderness of the metacarpophalangeal joints and wrists suggests articular disorder and hence rules out polymyalgia rheumatica.

ANSWER:

The correct answer is “rheumatoid arthritis.”

REFERENCES:

Maini R N. Chapter 19.5. Rheumatoid arthritis. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition.

Shah A, St. Clair E. Chapter 321. Rheumatoid Arthritis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18th edition.

Question 5.

A 20-year-old woman presents with bilateral conductive deafness, palpable purpura on the legs, and hemoptysis. A radiograph of the chest shows a thin-walled cavity in the left lower zone. Investigations reveal red cell casts in the urine and an elevated serum creatinine level (3 mg/dL). What is the most probable diagnosis? (AI)

1. Henoch-Schonlein purpura

2. Polyarteritis nodosa

3. Granulomatosis with polyangiitis

4. Disseminated tuberculosis

DISCUSSION:

With vasculitis, lung involvement is commonly seen with granulomatosis with polyangiitis, microscopic PAN, Churg-Struass disease, and Takayasu’s arteritis. Polyarteritis nodosa and Henoch-Schonlein purpura rarely show lung involvement. A triad of upper respiratory tract diseases (including rhinitis, sinusitis, and otitis media), lower respiratory disease (including pulmonary nodules, cavities, and hemoptysis) and glomerulonephritis (red cell cast, raised creatinine) characterizes granulomatosis with polyangiitis (Wegner's granulomatosis). Polyarteritis nodosa is not associated with glomerulonephritis (red cell casts), and Henoch-Schonlein purpura typically presents in children between 4 and 7 years of age. Disseminated tuberculosis is often associated with features such as fever, anorexia, and weight loss. In addition, a history of exposure to another patient with tuberculosis or a history of HIV infection is frequently elicited.

ANSWER:

The correct answer is “granulomatosis with polyangiitis.”

REFERENCES:

Langford CA, Fauci AS. Chapter 326. The Vasculitis Syndromes. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18th edition.

Wells AU, M. du Bois R. Chapter 18.11.5. The lung in vasculitis. In: Warrell DA, Cox TM, Firth JD, eds. Oxford Textbook of Medicine. 5th edition.

Question 6.

A 34-year-old woman complains of paleness and bluish discoloration of the hands upon exposure to cold for the last five years and recent difficulty in swallowing solid food. On examination, there is tight skin over the face and fingers....