{"id":36956,"date":"2026-06-06T09:12:21","date_gmt":"2026-06-06T03:42:21","guid":{"rendered":"https:\/\/atsixty.com\/?p=36956"},"modified":"2026-06-06T09:57:03","modified_gmt":"2026-06-06T04:27:03","slug":"rheumatology-myopathies-sjogrens-scleroderma","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/","title":{"rendered":"Myopathies, Sjogren's &amp; Scleroderma"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Myopathies, Sjogren's &amp; Scleroderma<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#rhmq06 *,#rhmq06 *::before,#rhmq06 *::after{box-sizing:border-box;margin:0;padding:0}\n#rhmq06{\n  --ter:#8B3D20;\n  --ter-light:#B85A38;\n  --ter-pale:#FDF0EB;\n  --ter-dark:#6B2D14;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n  --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n  --ink:#2C1810;--ink-mid:#5A3D30;--ink-soft:#9A7060;\n  --line:#E8DDD8;--cream:#FAF6F2;--warm:#FFFDF9;\n  font-family:'Source Serif 4',Georgia,serif;\n  font-size:16px;color:var(--ink);background:var(--cream);\n  line-height:1.7;padding:0 0 64px;\n}\n#rhmq06 .mr-header{background:var(--ter);color:#FFFDF9;padding:34px 24px 28px;text-align:center}\n#rhmq06 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#rhmq06 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#rhmq06 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#rhmq06 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#rhmq06 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#rhmq06 .mr-chip{background:rgba(255,255,255,0.13);border:1px solid rgba(255,255,255,0.22);border-radius:20px;padding:4px 13px;font-size:0.73rem}\n#rhmq06 .mr-sentinel{height:1px}\n#rhmq06 .mr-progress{position:fixed;top:0;left:0;right:0;z-index:9999;background:var(--warm);border-bottom:1px solid var(--line);box-shadow:0 2px 12px rgba(44,24,16,0.08);padding:9px 16px;display:none}\n#rhmq06 .mr-progress.visible{display:block}\n#rhmq06 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#rhmq06 .mr-pips{display:flex;align-items:center;justify-content:center}\n#rhmq06 .mr-pip-wrap{display:flex;align-items:center}\n#rhmq06 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#rhmq06 .mr-pip-line.done{background:var(--ter)}\n#rhmq06 .mr-pip{width:28px;height:28px;border-radius:50%;border:2px solid var(--line);background:var(--warm);display:flex;align-items:center;justify-content:center;font-size:0.63rem;font-weight:700;color:var(--ink-soft);transition:all 0.3s;flex-shrink:0}\n#rhmq06 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#rhmq06 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#rhmq06 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#rhmq06 .mr-case{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--ter);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(44,24,16,0.05)}\n#rhmq06 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#rhmq06 .mr-num{font-family:'Playfair Display',serif;font-size:2.2rem;font-weight:700;color:var(--ter);opacity:0.16;line-height:1;margin-top:-2px;flex-shrink:0}\n#rhmq06 .mr-meta{flex:1}\n#rhmq06 .mr-tag-row{display:flex;align-items:center;justify-content:space-between;margin-bottom:5px}\n#rhmq06 .mr-tag{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--ter);opacity:0.8}\n#rhmq06 .mr-diff{font-size:0.61rem;font-weight:700;letter-spacing:0.10em;text-transform:uppercase;color:var(--ink-soft)}\n#rhmq06 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#rhmq06 .mr-stem strong{font-weight:600}\n#rhmq06 .mr-stem em{font-style:italic}\n#rhmq06 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n#rhmq06 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#rhmq06 .mr-opt{display:flex;align-items:flex-start;gap:11px;padding:10px 14px;border:1.5px solid var(--line);border-radius:8px;cursor:pointer;background:var(--warm);transition:border-color 0.15s,background 0.15s;-webkit-tap-highlight-color:transparent}\n#rhmq06 .mr-opt:hover{border-color:var(--ter);background:var(--ter-pale)}\n#rhmq06 .mr-opt.locked{cursor:default}\n#rhmq06 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#rhmq06 .mr-opt.correct{border-color:var(--correct-border);background:var(--correct-bg);cursor:default}\n#rhmq06 .mr-opt.correct:hover{border-color:var(--correct-border);background:var(--correct-bg)}\n#rhmq06 .mr-opt.wrong{border-color:var(--wrong-border);background:var(--wrong-bg);cursor:default}\n#rhmq06 .mr-opt.wrong:hover{border-color:var(--wrong-border);background:var(--wrong-bg)}\n#rhmq06 .mr-opt.dimmed{opacity:0.35;cursor:default}\n#rhmq06 .mr-opt.dimmed:hover{border-color:var(--line);background:var(--warm)}\n#rhmq06 .mr-ltr{flex-shrink:0;width:20px;height:20px;border-radius:50%;border:1.5px solid var(--line);display:flex;align-items:center;justify-content:center;font-size:0.62rem;font-weight:700;color:var(--ink-soft);margin-top:2px;transition:all 0.15s}\n#rhmq06 .mr-opt.correct .mr-ltr{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#rhmq06 .mr-opt.wrong .mr-ltr{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#rhmq06 .mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#rhmq06 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#rhmq06 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n#rhmq06 .mr-exp{display:none;border-top:1px solid #c8e0d8;background:linear-gradient(180deg,#edf7f4 0%,#f4faf8 100%);padding:13px 20px 15px}\n#rhmq06 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:var(--correct);margin-bottom:6px}\n#rhmq06 .mr-exp-text{font-size:0.86rem;color:#1c4a3a;line-height:1.68}\n#rhmq06 .mr-exp-text strong{font-weight:600}\n#rhmq06 .mr-exp-text em{font-style:italic}\n#rhmq06 .mr-exp-extra{margin-top:11px;padding-top:10px;border-top:1px dashed #9ACCC4;font-size:0.84rem;color:#1c4a3a;line-height:1.66}\n#rhmq06 .mr-exp-extra-lbl{font-size:0.59rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:var(--ter);margin-bottom:4px;display:block}\n#rhmq06 .mr-exp-extra strong{font-weight:600}\n#rhmq06 .mr-exp-extra em{font-style:italic}\n#rhmq06 .mr-img-wrap{margin-top:14px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:14px;text-align:center}\n#rhmq06 .mr-img-wrap figcaption{font-size:0.73rem;color:var(--ink-soft);font-style:italic;margin-top:8px;line-height:1.4}\n#rhmq06 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#rhmq06 .mr-btn{background:var(--ter);color:#FFFDF9;border:none;border-radius:8px;padding:13px 44px;font-family:'Playfair Display',serif;font-size:1rem;font-weight:700;cursor:pointer;box-shadow:0 2px 8px rgba(139,61,32,0.28)}\n#rhmq06 .mr-btn:hover{background:var(--ter-dark)}\n#rhmq06 .mr-score{display:none;background:var(--warm);border:1px solid var(--line);border-top:4px solid var(--ter);border-radius:10px;margin:24px 0 0;box-shadow:0 2px 12px rgba(44,24,16,0.08);overflow:hidden}\n#rhmq06 .mr-score-in{padding:28px 24px;text-align:center}\n#rhmq06 .mr-score-ey{font-size:0.66rem;letter-spacing:0.14em;text-transform:uppercase;color:var(--ink-soft);margin-bottom:12px;font-weight:600}\n#rhmq06 .mr-ring{width:98px;height:98px;border-radius:50%;background:conic-gradient(var(--ter) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 16px;position:relative}\n#rhmq06 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#rhmq06 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#rhmq06 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--ter)}\n#rhmq06 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#rhmq06 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#rhmq06 .mr-score-net{font-size:0.9rem;color:var(--ter);font-weight:600;margin-bottom:4px}\n#rhmq06 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#rhmq06 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#rhmq06 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#rhmq06 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#rhmq06 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#rhmq06 .mr-band-s{background:var(--ter-pale);color:var(--ter)}\n#rhmq06 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ter);color:var(--ter);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#rhmq06 .mr-retry:hover{background:var(--ter);color:#FFFDF9}\n@media(max-width:480px){#rhmq06 .mr-title{font-size:1.4rem}#rhmq06 .mr-num{font-size:1.7rem}#rhmq06 .mr-stem{font-size:0.9rem}#rhmq06 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- Scleroderma antibody-subtype SVG for Q4 debrief -->\n<div id=\"rhmq06-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 540 160\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:540px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"540\" height=\"160\" rx=\"8\" fill=\"#F4F8F6\"\/>\n      <!-- Column headers -->\n      <rect x=\"10\" y=\"8\" width=\"155\" height=\"22\" rx=\"4\" fill=\"#8B3D20\" opacity=\"0.85\"\/>\n      <text x=\"87\" y=\"23\" text-anchor=\"middle\" fill=\"#fff\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Limited SSc (lcSSc)<\/text>\n      <rect x=\"192\" y=\"8\" width=\"155\" height=\"22\" rx=\"4\" fill=\"#3D5A80\" opacity=\"0.85\"\/>\n      <text x=\"269\" y=\"23\" text-anchor=\"middle\" fill=\"#fff\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Diffuse SSc (dcSSc)<\/text>\n      <rect x=\"374\" y=\"8\" width=\"155\" height=\"22\" rx=\"4\" fill=\"#2D6B47\" opacity=\"0.85\"\/>\n      <text x=\"451\" y=\"23\" text-anchor=\"middle\" fill=\"#fff\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Key Associations<\/text>\n      <!-- Row 1 \u2014 Antibody -->\n      <text x=\"14\" y=\"47\" fill=\"#8B3D20\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Antibody:<\/text>\n      <text x=\"14\" y=\"58\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Anti-centromere (ACA)<\/text>\n      <text x=\"196\" y=\"47\" fill=\"#3D5A80\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Antibody:<\/text>\n      <text x=\"196\" y=\"58\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Anti-Scl-70 (topoisomerase I)<\/text>\n      <text x=\"378\" y=\"47\" fill=\"#2D6B47\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">ACA:<\/text>\n      <text x=\"378\" y=\"58\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">PAH, CREST, late ILD<\/text>\n      <!-- Row 2 \u2014 Skin -->\n      <text x=\"14\" y=\"76\" fill=\"#8B3D20\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Skin:<\/text>\n      <text x=\"14\" y=\"87\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Distal to elbows\/knees<\/text>\n      <text x=\"196\" y=\"76\" fill=\"#3D5A80\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Skin:<\/text>\n      <text x=\"196\" y=\"87\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Trunk, face, proximal limbs<\/text>\n      <text x=\"378\" y=\"76\" fill=\"#2D6B47\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Scl-70:<\/text>\n      <text x=\"378\" y=\"87\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">ILD (early, severe), dcSSc<\/text>\n      <!-- Row 3 \u2014 Organs -->\n      <text x=\"14\" y=\"105\" fill=\"#8B3D20\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Organs:<\/text>\n      <text x=\"14\" y=\"116\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">PAH &gt;&gt; ILD; CREST<\/text>\n      <text x=\"196\" y=\"105\" fill=\"#3D5A80\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Organs:<\/text>\n      <text x=\"196\" y=\"116\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">ILD &gt;&gt; PAH; renal crisis<\/text>\n      <text x=\"378\" y=\"105\" fill=\"#2D6B47\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Anti-RNA pol III:<\/text>\n      <text x=\"378\" y=\"116\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Renal crisis; cancer risk<\/text>\n      <!-- Row 4 \u2014 Prognosis -->\n      <text x=\"14\" y=\"134\" fill=\"#8B3D20\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Prognosis:<\/text>\n      <text x=\"14\" y=\"145\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Better; slower progression<\/text>\n      <text x=\"196\" y=\"134\" fill=\"#3D5A80\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Prognosis:<\/text>\n      <text x=\"196\" y=\"145\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Worse; rapid fibrosis<\/text>\n      <text x=\"378\" y=\"134\" fill=\"#2D6B47\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Anti-PM-Scl:<\/text>\n      <text x=\"378\" y=\"145\" fill=\"#5A3D30\" font-size=\"8.5\" font-family=\"Georgia,serif\">Overlap: SSc + myositis<\/text>\n      <!-- Dividers -->\n      <line x1=\"182\" y1=\"8\" x2=\"182\" y2=\"152\" stroke=\"#C8D8D4\" stroke-width=\"1\"\/>\n      <line x1=\"364\" y1=\"8\" x2=\"364\" y2=\"152\" stroke=\"#C8D8D4\" stroke-width=\"1\"\/>\n    <\/svg>\n    <figcaption>\n      Systemic sclerosis subtypes and antibody associations. <strong>Anti-centromere<\/strong> &rarr; limited SSc (CREST), pulmonary arterial hypertension. <strong>Anti-Scl-70 (topoisomerase I)<\/strong> &rarr; diffuse SSc, early severe ILD. <strong>Anti-RNA polymerase III<\/strong> &rarr; diffuse SSc, scleroderma renal crisis, associated malignancy risk.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"rhmq06\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Rheumatology Series &middot; Round 06<\/div>\n    <div class=\"mr-title\">\n      Myopathies, Sjogren&apos;s &amp; Scleroderma<br><em>Clinical Reasoning<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and UPSC CMS<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"rhmq06-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"rhmq06-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"rhmq06-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"rhmq06-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"rhmq06-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"rhmq06-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"rhmq06-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"rhmq06-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"rhmq06-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"rhmq06-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"rhmq06-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"rhmq06-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"rhmq06-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"rhmq06-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #rhmq06 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'rhmq06';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    \/* ---- Q1 : Polymyositis vs Dermatomyositis ---- *\/\n    {\n      id:   1,\n      diff: 'Easy',\n      tag:  'Inflammatory Myopathy &mdash; PM vs DM',\n      stem: 'A <strong>44-year-old woman<\/strong> presents with a <strong>3-month history of progressive proximal muscle weakness<\/strong> &mdash; difficulty rising from a chair, climbing stairs, and raising her arms above her head. She has no muscle pain. Examination reveals <strong>violaceous discolouration of the upper eyelids<\/strong> (heliotrope rash), <strong>Gottron\\'s papules<\/strong> over the MCP and PIP joints, and <strong>mechanic\\'s hands<\/strong> (hyperkeratotic fissuring of the lateral fingers). CK is 3,800 IU\/L. ANA is positive; anti-Jo-1 is strongly positive. Pulmonary function tests show a restrictive pattern with reduced DLCO. Which statement about her diagnosis and the significance of anti-Jo-1 is <em>most accurate<\/em>?',\n      correct: 'She has dermatomyositis with antisynthetase syndrome; anti-Jo-1 positivity predicts interstitial lung disease, inflammatory arthritis, mechanic\\'s hands, and Raynaud\\'s phenomenon as a cluster; ILD is the leading cause of mortality in antisynthetase syndrome',\n      opts: [\n        'She has dermatomyositis with antisynthetase syndrome; anti-Jo-1 positivity predicts interstitial lung disease, inflammatory arthritis, mechanic\\'s hands, and Raynaud\\'s phenomenon as a cluster; ILD is the leading cause of mortality in antisynthetase syndrome',\n        'She has polymyositis; Gottron\\'s papules and heliotrope rash are not specific for dermatomyositis and can occur in any inflammatory myopathy; anti-Jo-1 is a non-specific myositis antibody that does not predict organ involvement',\n        'Anti-Jo-1 positivity with restrictive lung disease confirms hypersensitivity pneumonitis from an occupational exposure; the proximal myopathy is a paraneoplastic syndrome and malignancy screening with CT thorax-abdomen-pelvis is the immediate priority over immunosuppression',\n        'The combination of proximal weakness, elevated CK, and anti-Jo-1 positivity is diagnostic of inclusion body myositis (IBM); IBM is distinguished from polymyositis by its resistance to corticosteroids and its association with antisynthetase antibodies'\n      ],\n      exp:  '<strong>Dermatomyositis (DM)<\/strong> is distinguished from polymyositis by its <strong>pathognomonic skin features<\/strong>: <em>heliotrope rash<\/em> (violaceous periorbital oedema), <em>Gottron\\'s papules<\/em> (raised violaceous papules over MCP\/PIP\/DIP joints &mdash; knuckle pads), and <em>Gottron\\'s sign<\/em> (macular erythema over elbows, knees). <strong>Anti-Jo-1<\/strong> is the prototype antisynthetase antibody (targets histidyl-tRNA synthetase) and defines the <strong>antisynthetase syndrome<\/strong>: inflammatory myopathy + <strong>ILD<\/strong> (often NSIP pattern) + inflammatory arthritis + mechanic\\'s hands + Raynaud\\'s phenomenon + fever. <strong>ILD is the principal cause of morbidity and mortality<\/strong> in antisynthetase syndrome. <strong>Malignancy risk<\/strong> is highest in DM (particularly amyopathic DM) &mdash; ovarian, lung, GI cancers. IBM is a distinct entity: insidious onset over years, distal &gt; proximal weakness, finger flexor and quadriceps involvement, CK only mildly elevated, and it is <em>steroid-resistant<\/em> &mdash; antisynthetase antibodies are not associated.',\n      extra: '<strong>Myositis-specific antibodies (MSAs) &mdash; exam table:<\/strong><br>Anti-Jo-1 (anti-HRS): antisynthetase syndrome; ILD + myositis + arthritis + mechanic\\'s hands.<br>Anti-Mi-2: classic DM; florid skin disease; good steroid response; low ILD risk.<br>Anti-MDA5: amyopathic DM; rapidly progressive ILD (can be fatal within weeks); skin ulceration; low or absent CK despite severe ILD.<br>Anti-TIF1-&gamma; (anti-p155\/140): DM; strong association with malignancy (especially in adults &gt;40).<br>Anti-SRP: immune-mediated necrotising myopathy (IMNM); very high CK; severe weakness; poor steroid response; statins can trigger.<br>Anti-HMGCR: statin-associated IMNM; persists after statin withdrawal; requires immunosuppression.<br><strong>Histology distinction<\/strong>: PM shows endomysial CD8+ T-cell infiltration; DM shows perimysial\/perivascular CD4+ inflammation with perifascicular atrophy (pathognomonic for DM on biopsy).',\n      imgId: null\n    },\n\n    \/* ---- Q2 : Sjogren's Syndrome ---- *\/\n    {\n      id:   2,\n      diff: 'Medium',\n      tag:  'Sjogren\\'s Syndrome &mdash; Diagnosis &amp; Complications',\n      stem: 'A <strong>52-year-old woman<\/strong> presents with a <strong>4-year history of dry eyes and dry mouth<\/strong>, recurrent bilateral <strong>parotid gland enlargement<\/strong>, and fatigue. She has no features of RA, SLE, or scleroderma. Anti-SSA (Ro) is strongly positive; anti-SSB (La) is positive. ANA is 1:320, speckled pattern. Minor salivary gland biopsy shows focal lymphocytic sialadenitis with a focus score of <strong>2 foci per 4 mm&sup2;<\/strong>. She also has a <strong>serum protein electrophoresis showing a polyclonal hypergammaglobulinaemia<\/strong> and a <strong>serum IgM of 4.2 g\/L<\/strong>. What is the most important long-term complication to screen for in this patient, and what clinical features would heighten that suspicion?',\n      correct: 'Non-Hodgkin lymphoma (predominantly MALT lymphoma of parotid or salivary glands); risk factors include persistent parotid enlargement, palpable purpura, cryoglobulinaemia, low C4, and monoclonal IgM band on SPEP',\n      opts: [\n        'Non-Hodgkin lymphoma (predominantly MALT lymphoma of parotid or salivary glands); risk factors include persistent parotid enlargement, palpable purpura, cryoglobulinaemia, low C4, and monoclonal IgM band on SPEP',\n        'Primary biliary cholangitis (PBC); anti-mitochondrial antibodies should be checked immediately as PBC is the most common systemic complication of Sjogren\\'s syndrome and the elevated IgM confirms cholestatic liver disease',\n        'Pulmonary arterial hypertension; the polyclonal hypergammaglobulinaemia and elevated IgM indicate immune complex deposition in pulmonary vasculature; annual echocardiography is the recommended screening tool',\n        'Renal tubular acidosis type 1 (distal RTA) is the most feared long-term complication; the elevated IgM indicates tubular immune complex deposition and urgent urine pH and serum electrolytes are needed to exclude hypokalaemic paralysis'\n      ],\n      exp:  'Primary Sjogren\\'s syndrome (pSS) carries a <strong>15&ndash;44 fold increased risk of non-Hodgkin lymphoma<\/strong> compared to the general population, predominantly <strong>MALT (mucosa-associated lymphoid tissue) lymphoma<\/strong> arising in the parotid, submandibular, or lacrimal glands. High-risk features for lymphoma development: <strong>persistent parotid enlargement<\/strong>; palpable purpura; cryoglobulinaemia (type II); <strong>low C4<\/strong> (complement consumption); <strong>monoclonal IgM<\/strong> on serum protein electrophoresis; splenomegaly; peripheral neuropathy; high focus score on biopsy (&ge;3). This patient has an elevated IgM &mdash; it must be checked whether this represents a monoclonal band (worrying) or polyclonal elevation. The <strong>EULAR Sjogren\\'s Syndrome Disease Activity Index (ESSDAI)<\/strong> helps stratify systemic disease. The <strong>focus score &ge;1 foci\/4 mm&sup2;<\/strong> on minor salivary gland biopsy satisfies the ACR\/EULAR 2016 classification criteria (score of 3 for this item).',\n      extra: '<strong>ACR\/EULAR 2016 Primary Sjogren\\'s Classification Criteria<\/strong> (applicable when ocular or oral dryness present): labial salivary gland biopsy with focal lymphocytic sialadenitis and focus score &ge;1\/4mm&sup2; (3 points); anti-SSA\/Ro positivity (3 points); abnormal ocular staining score &ge;5 (1 point); Schirmer\\'s test &le;5 mm\/5 min (1 point); unstimulated salivary flow &le;0.1 mL\/min (1 point). Score &ge;4 classifies as pSS. <strong>Extraglandular manifestations<\/strong>: arthralgia\/arthritis (most common); interstitial nephritis (distal RTA type 1 &mdash; causes hypokalaemia and nephrocalcinosis); peripheral neuropathy (sensory &gt; motor); CNS involvement (rare); vasculitis. <strong>Distal RTA in Sjogren\\'s<\/strong>: inability to acidify urine below pH 5.5 despite systemic acidosis; hypokalaemia can be severe enough to cause paralysis &mdash; a genuine emergency. Check urine pH and serum K+ in all pSS patients with fatigue and muscle weakness.',\n      imgId: null\n    },\n\n    \/* ---- Q3 : Antisynthetase ILD vs Steroid Myopathy ---- *\/\n    {\n      id:   3,\n      diff: 'Medium',\n      tag:  'Inflammatory Myopathy &mdash; Treatment Trap',\n      stem: 'A <strong>48-year-old man<\/strong> with biopsy-confirmed polymyositis was started on <strong>prednisolone 60 mg\/day six months ago<\/strong>. His initial CK of 6,200 IU\/L normalised within 8 weeks and his proximal weakness improved markedly. However, over the past <strong>six weeks<\/strong> he has developed <strong>worsening proximal muscle weakness again<\/strong>, now affecting hip flexors and shoulder abductors. Repeat CK is <strong>42 IU\/L<\/strong> (normal). ESR is 12 mm\/hr. EMG shows a myopathic pattern with short-duration, small-amplitude polyphasic units but no spontaneous activity (no fibrillations or positive sharp waves). Which diagnosis explains this new weakness and what is the correct management?',\n      correct: 'Steroid myopathy (iatrogenic); the normal CK and absence of spontaneous EMG activity distinguish it from a polymyositis flare; management is to reduce the prednisolone dose, not increase it',\n      opts: [\n        'Steroid myopathy (iatrogenic); the normal CK and absence of spontaneous EMG activity distinguish it from a polymyositis flare; management is to reduce the prednisolone dose, not increase it',\n        'Polymyositis relapse; the myopathic EMG pattern confirms active muscle inflammation regardless of the normal CK; prednisolone should be increased to 80 mg\/day and azathioprine added as a steroid-sparing agent immediately',\n        'Inclusion body myositis emerging over time; IBM frequently mimics polymyositis initially and becomes apparent only after months of failed steroid therapy; the normal CK is characteristic and muscle biopsy will show rimmed vacuoles and 15&ndash;18 nm tubulofilaments',\n        'Hypokalaemic myopathy from corticosteroid-induced mineralocorticoid excess; serum potassium should be checked urgently and potassium supplementation started before altering the prednisolone dose'\n      ],\n      exp:  '<strong>Steroid myopathy<\/strong> is a well-recognised complication of prolonged high-dose corticosteroid therapy, typically developing after <strong>4&ndash;6 weeks<\/strong> on doses &ge;40 mg\/day prednisolone. It preferentially affects <strong>type II (fast-twitch) muscle fibres<\/strong>, causing proximal weakness indistinguishable clinically from the underlying inflammatory myopathy. The critical distinguishing features: <strong>CK is normal or low<\/strong> (no muscle necrosis), <strong>ESR\/CRP are normal<\/strong>, and <strong>EMG shows no spontaneous activity<\/strong> (no fibrillations or positive sharp waves) &mdash; inflammatory myopathy produces spontaneous activity. Biopsy shows type II fibre atrophy without inflammation. <strong>Management: reduce the corticosteroid dose<\/strong>. Increasing steroids (the instinctive response if misdiagnosed as a flare) worsens the myopathy. This is one of the most consequential clinical traps in rheumatology.',\n      extra: '<strong>Distinguishing polymyositis flare from steroid myopathy &mdash; the exam table:<\/strong><br>CK: elevated in PM flare; normal in steroid myopathy.<br>ESR\/CRP: elevated in PM flare; normal in steroid myopathy.<br>EMG spontaneous activity (fibrillations, PSWs): present in PM flare; absent in steroid myopathy.<br>MRI muscle: oedema in PM flare; fatty infiltration in steroid myopathy (chronic).<br>Biopsy: inflammatory infiltrate in PM; type II fibre atrophy, no inflammation in steroid myopathy.<br><strong>Azathioprine<\/strong> is the first-line steroid-sparing agent for inflammatory myopathy (started 6&ndash;8 weeks after prednisolone, allows dose tapering). <strong>Methotrexate<\/strong> is an alternative but avoided in ILD-associated myositis (pulmonary toxicity risk). <strong>IVIg<\/strong> is effective in DM and is used for refractory disease or when rapid response is needed (e.g., dysphagia from pharyngeal muscle involvement).',\n      imgId: null\n    },\n\n    \/* ---- Q4 : Systemic Sclerosis \u2014 Scleroderma Renal Crisis ---- *\/\n    {\n      id:   4,\n      diff: 'Hard',\n      tag:  'Systemic Sclerosis &mdash; Renal Crisis',\n      stem: 'A <strong>38-year-old woman<\/strong> with a <strong>14-month history of diffuse cutaneous systemic sclerosis<\/strong> (skin thickening proximal to elbows, trunk, and face; anti-Scl-70 positive) presents acutely with <strong>severe headache, blurred vision, and BP 196\/118 mmHg<\/strong>. Serum creatinine has risen from 78 to 312 &mu;mol\/L over <strong>10 days<\/strong>. Blood film shows <strong>fragmented red cells (schistocytes)<\/strong> and platelet count is 62 &times; 10&sup9;\/L. Urinalysis shows 2+ proteinuria and haematuria. She has been on <strong>prednisolone 20 mg\/day<\/strong> for worsening skin thickening for the past 6 weeks. Which statement about this emergency and its management is <em>most accurate<\/em>?',\n      correct: 'This is scleroderma renal crisis (SRC); ACE inhibitors (captopril) are the treatment of choice and must be started immediately regardless of the degree of renal impairment; corticosteroids at doses &ge;15 mg\/day prednisolone are a major risk factor for SRC and this patient\\'s steroid use has likely precipitated the crisis',\n      opts: [\n        'This is scleroderma renal crisis (SRC); ACE inhibitors (captopril) are the treatment of choice and must be started immediately regardless of the degree of renal impairment; corticosteroids at doses &ge;15 mg\/day prednisolone are a major risk factor for SRC and this patient\\'s steroid use has likely precipitated the crisis',\n        'The schistocytes and thrombocytopaenia confirm thrombotic thrombocytopaenic purpura (TTP) complicating scleroderma; plasma exchange must be started immediately and ACE inhibitors are contraindicated as they worsen TTP-associated renal failure',\n        'This is hypertensive emergency from essential hypertension coincidentally occurring in a scleroderma patient; IV labetalol is the preferred agent; ACE inhibitors are contraindicated in scleroderma renal crisis because they cause irreversible renal arteriolar vasospasm',\n        'Anti-Scl-70 positivity confirms diffuse SSc but SRC only occurs in limited cutaneous SSc (lcSSc) associated with anti-centromere antibodies; this patient\\'s acute presentation is more consistent with scleroderma-associated pulmonary arterial hypertension causing secondary renal hypoperfusion'\n      ],\n      exp:  '<strong>Scleroderma Renal Crisis (SRC)<\/strong> is a medical emergency occurring in <strong>10&ndash;15% of diffuse SSc<\/strong> patients, typically in the first <strong>4&ndash;5 years<\/strong> of disease. It is characterised by: acute onset hypertension (often &gt;150\/90 mmHg, frequently severe), rapidly progressive oliguric renal failure, and microangiopathic haemolytic anaemia (schistocytes, thrombocytopaenia) &mdash; a TMA picture. Pathology: intimal proliferation and fibrinoid necrosis of small renal arteries causing activation of the renin-angiotensin system. <strong>Risk factors<\/strong>: early diffuse SSc, rapid skin progression, <strong>anti-RNA polymerase III antibody<\/strong> (not anti-Scl-70, though both occur in dcSSc), corticosteroids &ge;15 mg\/day prednisolone. <strong>Treatment<\/strong>: <strong>ACE inhibitor (captopril)<\/strong> is the cornerstone &mdash; start immediately, titrate rapidly. Do NOT withhold because of elevated creatinine &mdash; ACE inhibition interrupts the renin-mediated cycle. Up to 50% still require dialysis, but 50% of those can discontinue dialysis after 1&ndash;2 years with continued ACE inhibition.',\n      extra: '<strong>Scleroderma antibody &mdash; renal crisis link<\/strong>: anti-RNA polymerase III is the antibody most strongly associated with SRC (present in ~25% of dcSSc; SRC risk up to 25% in anti-RNA pol III+ patients). Importantly, anti-RNA pol III is also associated with <strong>synchronous malignancy<\/strong> &mdash; particularly breast and lung cancer diagnosed within 3 years of SSc onset. Screen for malignancy at SSc diagnosis in anti-RNA pol III+ patients. <strong>Prophylactic ACE inhibitor in SSc<\/strong>: <em>not recommended<\/em> in normotensive SSc patients &mdash; early trials suggested potential harm by masking warning hypertension. <strong>CREST syndrome<\/strong> (limited SSc variant): Calcinosis, Raynaud\\'s, oEsophageal dysmotility, Sclerodactyly, Telangiectasia. Anti-centromere antibody. Complications: PAH (leading cause of death in lcSSc) and late ILD. Renal crisis is rare. <strong>Iloprost<\/strong> (IV prostacyclin analogue): used for severe Raynaud\\'s and digital ulcers in SSc.',\n      imgId: 'rhmq06-img1'\n    },\n\n    \/* ---- Q5 : MCTD \u2014 Overlap Syndrome ---- *\/\n    {\n      id:   5,\n      diff: 'Hard',\n      tag:  'MCTD &mdash; Mixed Connective Tissue Disease',\n      stem: 'A <strong>31-year-old woman<\/strong> presents with a <strong>2-year history of Raynaud\\'s phenomenon<\/strong>, <strong>swollen sausage-like fingers<\/strong> (puffy hands), <strong>inflammatory polyarthritis<\/strong> of small and large joints, and <strong>proximal muscle weakness<\/strong> with a CK of 2,100 IU\/L. She has no malar rash, no oral ulcers, no skin thickening beyond the fingers, and no sicca symptoms. ANA is strongly positive (1:1280, speckled pattern). Anti-U1-RNP antibody titre is markedly elevated. Anti-dsDNA, anti-Sm, anti-SSA, anti-SSB, and anti-Scl-70 are all negative. Which statement most accurately characterises this diagnosis, its distinguishing serological feature, and its most feared complication?',\n      correct: 'Mixed connective tissue disease (MCTD) is defined by high-titre anti-U1-RNP in the absence of antibodies specific for other CTDs; it overlaps features of SLE, SSc, and myositis; pulmonary arterial hypertension is the leading cause of death in MCTD',\n      opts: [\n        'Mixed connective tissue disease (MCTD) is defined by high-titre anti-U1-RNP in the absence of antibodies specific for other CTDs; it overlaps features of SLE, SSc, and myositis; pulmonary arterial hypertension is the leading cause of death in MCTD',\n        'This presentation is consistent with undifferentiated connective tissue disease (UCTD); MCTD requires the simultaneous presence of features of all three diseases (SLE, SSc, and myositis) plus positive anti-Sm antibody; anti-U1-RNP positivity alone does not satisfy MCTD criteria',\n        'The high-titre ANA with speckled pattern and puffy hands confirms early diffuse systemic sclerosis; anti-U1-RNP is a surrogate marker for anti-Scl-70 positivity in early disease before skin thickening develops; scleroderma renal crisis prophylaxis with ACE inhibitors should be started immediately',\n        'The combination of myositis, arthritis, and Raynaud\\'s in a young woman with speckled ANA confirms antisynthetase syndrome; anti-U1-RNP is the same as anti-Jo-1 by a different nomenclature; ILD is the leading cause of death and high-resolution CT chest is the investigation of choice'\n      ],\n      exp:  '<strong>Mixed Connective Tissue Disease (MCTD)<\/strong> is defined by the <strong>Sharp criteria<\/strong>: high-titre anti-U1-RNP (anti-snRNP) antibody PLUS overlapping clinical features of SLE (arthritis, serositis), SSc (Raynaud\\'s, puffy hands, sclerodactyly), and\/or polymyositis (proximal weakness, elevated CK), in the absence of antibodies specific for individual CTDs (anti-dsDNA, anti-Sm, anti-Scl-70, anti-SSA). The <strong>speckled ANA pattern<\/strong> reflects anti-RNP. <strong>Puffy hands<\/strong> (non-pitting oedema of fingers) in the early morning are a classic and underappreciated clue to MCTD. <strong>Most feared complication: pulmonary arterial hypertension (PAH)<\/strong> &mdash; occurs in 10&ndash;45% of MCTD patients and is the leading cause of death, similar to limited SSc. Annual echocardiography is recommended for PAH surveillance. Unlike SSc, MCTD generally has a better prognosis and responds well to corticosteroids for most manifestations.',\n      extra: '<strong>Anti-U1-RNP vs anti-Sm<\/strong>: both target components of the spliceosomal snRNP complex. Anti-Sm (anti-Smith) is <em>specific<\/em> for SLE and its presence argues against MCTD (where anti-Sm should be absent). Anti-U1-RNP can be positive in SLE (but at lower titres and alongside anti-Sm); in MCTD it is the <em>sole<\/em> defining antibody at high titre. <strong>Overlap syndromes vs MCTD<\/strong>: MCTD requires positive anti-U1-RNP as the unifying serological marker; overlap syndromes are defined clinically (features of two CTDs) without necessarily having anti-U1-RNP. <strong>Undifferentiated CTD (UCTD)<\/strong>: early CTD features that do not yet satisfy criteria for any defined CTD; ANA positive, non-specific symptoms; approximately 25&ndash;30% evolve into a defined CTD over 5&ndash;10 years. <strong>MCTD complications by organ<\/strong>: PAH (leading cause of death); ILD (milder than SSc); oesophageal dysmotility; aseptic meningitis (rare); renal disease (less severe than SLE).'\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(sfx) { return byId(NS + '-' + sfx); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, t;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      t = a[i]; a[i] = a[j]; a[j] = t;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wl, wp, line, pip;\n    if (!cont) return;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wl = document.createElement('div'); wl.className = 'mr-pip-wrap';\n        line = document.createElement('div'); line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wl.appendChild(line); cont.appendChild(wl);\n      }\n      wp  = document.createElement('div'); wp.className = 'mr-pip-wrap';\n      pip = document.createElement('div'); pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wp.appendChild(pip); cont.appendChild(wp);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, nd, meta, tagRow, tg, dl,\n        st, rule, od, ed, lb, tx, ep, epl, ept, imgSrc, imgDiv, j, oe, ls, ts;\n    cont = gid('cases');\n    if (!cont) return;\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    if (gid('score')) gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q    = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div'); card.className = 'mr-case';\n      top  = document.createElement('div'); top.className  = 'mr-case-top';\n      nd   = document.createElement('div'); nd.className   = 'mr-num';\n      nd.textContent = q.id < 10 ? '0' + q.id : String(q.id);\n      meta = document.createElement('div'); meta.className = 'mr-meta';\n\n      tagRow = document.createElement('div'); tagRow.className = 'mr-tag-row';\n      tg = document.createElement('div'); tg.className = 'mr-tag'; tg.innerHTML = q.tag;\n      dl = document.createElement('div'); dl.className = 'mr-diff'; dl.textContent = q.diff;\n      tagRow.appendChild(tg); tagRow.appendChild(dl);\n\n      st = document.createElement('div'); st.className = 'mr-stem'; st.innerHTML = q.stem;\n      meta.appendChild(tagRow); meta.appendChild(st);\n      top.appendChild(nd); top.appendChild(meta);\n      card.appendChild(top);\n\n      rule = document.createElement('div'); rule.className = 'mr-rule';\n      card.appendChild(rule);\n\n      od = document.createElement('div'); od.className = 'mr-opts';\n      for (j = 0; j < opts.length; j++) {\n        oe = document.createElement('div'); oe.className = 'mr-opt';\n        oe.id = NS + '-o' + q.id + '-' + j;\n        oe.setAttribute('role', 'button'); oe.setAttribute('tabindex', '0');\n        ls = document.createElement('span'); ls.className = 'mr-ltr'; ls.textContent = LTRS[j];\n        ts = document.createElement('span'); ts.className = 'mr-opt-text'; ts.innerHTML = opts[j];\n        oe.appendChild(ls); oe.appendChild(ts); od.appendChild(oe);\n        (function (qid, oi) {\n          oe.addEventListener('click', function () { pick(qid, oi); });\n        }(q.id, j));\n      }\n      card.appendChild(od);\n\n      ed  = document.createElement('div'); ed.className = 'mr-exp'; ed.id = NS + '-exp' + q.id;\n      lb  = document.createElement('div'); lb.className = 'mr-exp-lbl'; lb.textContent = 'Debrief';\n      tx  = document.createElement('div'); tx.className = 'mr-exp-text'; tx.innerHTML = q.exp;\n      ed.appendChild(lb); ed.appendChild(tx);\n\n      if (q.imgId) {\n        imgSrc = byId(q.imgId);\n        if (imgSrc) {\n          imgDiv = document.createElement('div');\n          imgDiv.innerHTML = imgSrc.innerHTML;\n          ed.appendChild(imgDiv);\n        }\n      }\n\n      if (q.extra) {\n        ep  = document.createElement('div'); ep.className = 'mr-exp-extra';\n        epl = document.createElement('span'); epl.className = 'mr-exp-extra-lbl'; epl.textContent = 'Extra Points';\n        ept = document.createElement('div'); ept.innerHTML = q.extra;\n        ep.appendChild(epl); ep.appendChild(ept);\n        ed.appendChild(ep);\n      }\n\n      card.appendChild(ed);\n      cont.appendChild(card);\n    }\n  }\n\n  function pick(qid, oi) {\n    var q, opts, i, el, ok;\n    if (answers[qid] !== undefined || done) return;\n    q = null;\n    for (i = 0; i < QS.length; i++) { if (QS[i].id === qid) { q = QS[i]; break; } }\n    if (!q) return;\n    opts = shuffled[qid];\n    ok   = (opts[oi] === q.correct);\n    answers[qid] = ok ? 'c' : 'w';\n    answered++;\n    for (i = 0; i < opts.length; i++) {\n      el = byId(NS + '-o' + qid + '-' + i);\n      if (!el) continue;\n      el.className = opts[i] === q.correct ? 'mr-opt correct locked'\n                   : i === oi              ? 'mr-opt wrong locked'\n                                           : 'mr-opt dimmed locked';\n    }\n    var ex = byId(NS + '-exp' + qid); if (ex) ex.style.display = 'block';\n    var pp = byId(NS + '-pip' + qid); if (pp) pp.className = 'mr-pip ' + (ok ? 'correct' : 'wrong');\n    if (qid > 1) { var pl = gid('pl' + qid); if (pl) pl.className = 'mr-pip-line done'; }\n  }\n\n  function showScore() {\n    var c, w, s, net, pct, disp, vlist, vi, sc;\n    if (done) return;\n    done = true;\n    c   = countVal('c'); w = countVal('w'); s = TOTAL - answered;\n    net  = c * 4 - w;\n    pct  = Math.max(0, Math.round((net \/ MAX) * 100));\n    disp = Math.min(100, Math.max(0, pct));\n    var rg = gid('ring');\n    if (rg) rg.style.background = 'conic-gradient(#8B3D20 ' + disp + '%, #E8DDD8 0%)';\n    var pe = gid('pct'); if (pe) pe.textContent = pct + '%';\n    var ne = gid('net'); if (ne) ne.textContent = 'Net Score: ' + net + ' \/ ' + MAX;\n    vlist = [\n      [5, 'Flawless. Every antibody, every overlap \\u2014 this round had no secrets for you.'],\n      [4, 'Strong \\u2014 one distinction worth a final read before exam day.'],\n      [3, 'Solid base \\u2014 the steroid myopathy trap and SRC management carry the marks.'],\n      [2, 'Halfway \\u2014 the MSA table and MCTD vs overlap syndromes repay close reading.'],\n      [0, 'These conditions reward antibody pattern recognition. One more pass through the debrief panels will make it click.']\n    ];\n    var ve = gid('verdict');\n    if (ve) {\n      ve.textContent = vlist[4][1];\n      for (vi = 0; vi < vlist.length; vi++) {\n        if (c >= vlist[vi][0]) { ve.textContent = vlist[vi][1]; break; }\n      }\n    }\n    var cc = gid('ct-c'); if (cc) cc.textContent = '\\u2705 ' + c + ' Correct';\n    var cw = gid('ct-w'); if (cw) cw.textContent = '\\u274C ' + w + ' Wrong';\n    var cs = gid('ct-s'); if (cs) cs.textContent = '\\u23ED ' + s + ' Skipped';\n    sc = gid('score');\n    if (sc) { sc.style.display = 'block'; sc.scrollIntoView({ behavior: 'smooth', block: 'center' }); }\n  }\n\n  function initObserver() {\n    var sn = gid('sentinel'), bar = gid('progress');\n    if (!sn || !bar || !window.IntersectionObserver) return;\n    new IntersectionObserver(function (en) {\n      bar.className = en[0].isIntersecting ? 'mr-progress' : 'mr-progress visible';\n    }, { threshold: 0 }).observe(sn);\n  }\n\n  function init() {\n    var sb = gid('submit'), rb = gid('retry');\n    if (!sb || !rb) return;\n    sb.addEventListener('click', showScore);\n    rb.addEventListener('click', function () { build(); window.scrollTo(0, 0); });\n    initObserver();\n    build();\n  }\n\n  function tryInit(n) {\n    if (document.getElementById('rhmq06-cases')) {\n      init();\n    } else if (n < 40) {\n      setTimeout(function () { tryInit(n + 1); }, 50);\n    }\n  }\n\n  tryInit(0);\n\n}());\n<\/script>\n\n\n","protected":false},"excerpt":{"rendered":"<p>Morning Rounds \u00b7 Myopathies, Sjogren's &amp; Scleroderma Limited SSc (lcSSc) Diffuse SSc (dcSSc) Key Associations Antibody: Anti-centromere (ACA) Antibody: Anti-Scl-70 (topoisomerase I) ACA: PAH, CREST, late ILD Skin: Distal to elbows\/knees Skin: Trunk, face, proximal limbs Scl-70: ILD (early, severe), dcSSc Organs: PAH &gt;&gt; ILD; CREST Organs: ILD &gt;&gt; PAH; renal crisis Anti-RNA pol III:&hellip;&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[74,24,64],"tags":[],"class_list":["post-36956","post","type-post","status-publish","format-standard","hentry","category-morning-rounds","category-neet-pg","category-orthopaedics"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Myopathies, Sjogren&#039;s &amp; Scleroderma - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Myopathies, Sjogren&#039;s &amp; Scleroderma - atsixty\" \/>\n<meta property=\"og:description\" content=\"Morning Rounds \u00b7 Myopathies, Sjogren&#039;s &amp; Scleroderma Limited SSc (lcSSc) Diffuse SSc (dcSSc) Key Associations Antibody: Anti-centromere (ACA) Antibody: Anti-Scl-70 (topoisomerase I) ACA: PAH, CREST, late ILD Skin: Distal to elbows\/knees Skin: Trunk, face, proximal limbs Scl-70: ILD (early, severe), dcSSc Organs: PAH &gt;&gt; ILD; CREST Organs: ILD &gt;&gt; PAH; renal crisis Anti-RNA pol III:&hellip;&nbsp;\" \/>\n<meta property=\"og:url\" content=\"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/\" \/>\n<meta property=\"og:site_name\" content=\"atsixty\" \/>\n<meta property=\"article:published_time\" content=\"2026-06-06T03:42:21+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-06-06T04:27:03+00:00\" \/>\n<meta name=\"author\" content=\"Avi\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Avi\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/\"},\"author\":{\"name\":\"Avi\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"headline\":\"Myopathies, Sjogren's &amp; Scleroderma\",\"datePublished\":\"2026-06-06T03:42:21+00:00\",\"dateModified\":\"2026-06-06T04:27:03+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/\"},\"wordCount\":156,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"articleSection\":[\"Morning Rounds\",\"NEET PG\",\"Orthopaedics\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/\",\"url\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/\",\"name\":\"Myopathies, Sjogren's &amp; Scleroderma - atsixty\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#website\"},\"datePublished\":\"2026-06-06T03:42:21+00:00\",\"dateModified\":\"2026-06-06T04:27:03+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/neet-pg\\\/rheumatology-myopathies-sjogrens-scleroderma\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/atsixty.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Myopathies, Sjogren's &amp; Scleroderma\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/#website\",\"url\":\"https:\\\/\\\/atsixty.com\\\/\",\"name\":\"At Sixty\",\"description\":\"The Option Taken\",\"publisher\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/atsixty.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":[\"Person\",\"Organization\"],\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\",\"name\":\"Avi\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"url\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"contentUrl\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"width\":200,\"height\":200,\"caption\":\"Avi\"},\"logo\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\"},\"sameAs\":[\"https:\\\/\\\/atsixty.com\"],\"url\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/author\\\/avinaux\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Myopathies, Sjogren's &amp; Scleroderma - atsixty","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/","og_locale":"en_US","og_type":"article","og_title":"Myopathies, Sjogren's &amp; Scleroderma - atsixty","og_description":"Morning Rounds \u00b7 Myopathies, Sjogren's &amp; Scleroderma Limited SSc (lcSSc) Diffuse SSc (dcSSc) Key Associations Antibody: Anti-centromere (ACA) Antibody: Anti-Scl-70 (topoisomerase I) ACA: PAH, CREST, late ILD Skin: Distal to elbows\/knees Skin: Trunk, face, proximal limbs Scl-70: ILD (early, severe), dcSSc Organs: PAH &gt;&gt; ILD; CREST Organs: ILD &gt;&gt; PAH; renal crisis Anti-RNA pol III:&hellip;&nbsp;","og_url":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/","og_site_name":"atsixty","article_published_time":"2026-06-06T03:42:21+00:00","article_modified_time":"2026-06-06T04:27:03+00:00","author":"Avi","twitter_card":"summary_large_image","twitter_misc":{"Written by":"Avi","Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/#article","isPartOf":{"@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/"},"author":{"name":"Avi","@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"headline":"Myopathies, Sjogren's &amp; Scleroderma","datePublished":"2026-06-06T03:42:21+00:00","dateModified":"2026-06-06T04:27:03+00:00","mainEntityOfPage":{"@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/"},"wordCount":156,"commentCount":0,"publisher":{"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"articleSection":["Morning Rounds","NEET PG","Orthopaedics"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/","url":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/","name":"Myopathies, Sjogren's &amp; Scleroderma - atsixty","isPartOf":{"@id":"https:\/\/atsixty.com\/#website"},"datePublished":"2026-06-06T03:42:21+00:00","dateModified":"2026-06-06T04:27:03+00:00","breadcrumb":{"@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/atsixty.com\/index.php\/neet-pg\/rheumatology-myopathies-sjogrens-scleroderma\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/atsixty.com\/"},{"@type":"ListItem","position":2,"name":"Myopathies, Sjogren's &amp; Scleroderma"}]},{"@type":"WebSite","@id":"https:\/\/atsixty.com\/#website","url":"https:\/\/atsixty.com\/","name":"At Sixty","description":"The Option Taken","publisher":{"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/atsixty.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":["Person","Organization"],"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d","name":"Avi","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","url":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","contentUrl":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","width":200,"height":200,"caption":"Avi"},"logo":{"@id":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png"},"sameAs":["https:\/\/atsixty.com"],"url":"https:\/\/atsixty.com\/index.php\/author\/avinaux\/"}]}},"_links":{"self":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36956","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/comments?post=36956"}],"version-history":[{"count":1,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36956\/revisions"}],"predecessor-version":[{"id":36957,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36956\/revisions\/36957"}],"wp:attachment":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/media?parent=36956"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/categories?post=36956"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/tags?post=36956"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}