Immunosuppressive Agents Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Immunosuppressive Agents. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Immunosuppressive Agents Indian Medical PG Question 1: All these drugs are known to exacerbate psoriasis, except:
- A. Beta blocker
- B. Hydroxychloroquine
- C. Ciclosporin (Correct Answer)
- D. Lithium
Immunosuppressive Agents Explanation: ***Ciclosporin***
- **Ciclosporin** is an immunosuppressant often used to **treat severe psoriasis**, not exacerbate it.
- It works by inhibiting the activation of T-cells, which are central to the pathogenesis of psoriasis.
*Beta blocker*
- **Beta-blockers**, particularly non-selective ones like **propranolol**, can worsen existing psoriasis or induce new lesions.
- The mechanism is thought to involve effects on beta-adrenergic receptors in the skin, leading to inflammation.
*Hydroxychloroquine*
- **Hydroxychloroquine**, an antimalarial and immunosuppressant, can trigger or exacerbate psoriasis, especially **pustular psoriasis**.
- It likely affects keratinocyte proliferation and immune responses in the skin.
*Lithium*
- **Lithium** is a mood stabilizer that is known to exacerbate or trigger various forms of psoriasis, including **plaque psoriasis** and **pustular psoriasis**.
- The mechanism is believed to involve alterations in cyclic AMP metabolism and arachidonic acid pathways within keratinocytes.
Immunosuppressive Agents Indian Medical PG Question 2: All of the following are used in systemic therapy of psoriasis except
- A. Methotrexate
- B. Cyclosporine
- C. Oral glucocorticoids (Correct Answer)
- D. Acitretin
Immunosuppressive Agents Explanation: ***Oral glucocorticoids***
- **Oral glucocorticoids** are generally avoided in psoriasis because they can precipitate severe **rebound flares** upon discontinuation or during dose tapering.
- While they can temporarily suppress inflammation, the risk of worsening psoriasis and other systemic side effects makes them unsuitable for long-term systemic therapy.
*Methotrexate*
- **Methotrexate** is a commonly used systemic agent for psoriasis due to its **immunosuppressive** and **anti-proliferative effects**, targeting rapidly dividing cells.
- It works by inhibiting dihydrofolate reductase and is typically given once weekly for chronic plaque psoriasis.
*Cyclosporine*
- **Cyclosporine** is an effective systemic immunosuppressant used for severe, resistant psoriasis, particularly when rapid control is needed.
- It primarily acts by inhibiting **T-cell activation** and proliferation, thereby reducing the inflammatory response in psoriasis.
*Acitretin*
- **Acitretin** is an oral retinoid derivative of vitamin A, used in severe forms of psoriasis, especially **pustular** and **erythrodermic** types.
- It works by modulating **keratinocyte differentiation** and proliferation, helping to normalize skin cell growth.
Immunosuppressive Agents Indian Medical PG Question 3: Which of the following anesthetic agent can cause adrenocortical suppression?
- A. Halothane
- B. Ketamine
- C. Etomidate (Correct Answer)
- D. Propofol
Immunosuppressive Agents Explanation: ***Etomidate***
- Etomidate is a common **IV anesthetic** that causes dose-dependent, reversible **adrenocortical suppression** by inhibiting the enzyme **11β-hydroxylase**.
- This enzyme is crucial for the synthesis of **cortisol** and other adrenal steroids, leading to a temporary decrease in their production, which can be clinically relevant in critically ill patients.
*Halothane*
- Halothane is an **inhaled anesthetic** known for its potential to cause **hepatotoxicity** (halothane hepatitis) but is not directly associated with adrenocortical suppression.
- Its primary cardiovascular effect is **myocardial depression**, leading to reduced cardiac output and hypotension.
*Ketamine*
- Ketamine is a **dissociative anesthetic** that generally has minimal effects on the adrenal cortex and can even cause a **sympathomimetic effect**, leading to increased heart rate and blood pressure.
- It is known for its **bronchodilatory** properties and is often used in patients with asthma or in situations where hemodynamic stability is crucial.
*Propofol*
- Propofol is a widely used **IV anesthetic** that often causes **hemodynamic depression** (hypotension) and respiratory depression but does not directly induce adrenocortical suppression.
- It is rapidly metabolized and is associated with a clear-headed recovery, making it suitable for outpatient procedures.
Immunosuppressive Agents Indian Medical PG Question 4: A 23-year-old female underwent kidney transplantation and developed acute humoral rejection after 8 days, which was successfully managed with tacrolimus and another drug that suppresses both B and T lymphocytes. What is the drug that targets both B and T lymphocytes by inhibiting de novo synthesis of purines?
- A. Prednisone
- B. Methotrexate
- C. Mycophenolate mofetil (Correct Answer)
- D. Cyclophosphamide
Immunosuppressive Agents Explanation: ***Mycophenolate mofetil***
- This drug inhibits **inosine monophosphate dehydrogenase**, an enzyme crucial for the **de novo synthesis of guanine nucleotides** in lymphocytes.
- This selective inhibition effectively suppresses the proliferation and function of both **B and T lymphocytes**, making it a cornerstone in preventing transplant rejection.
*Methotrexate*
- **Methotrexate** is an **antimetabolite** that primarily inhibits **dihydrofolate reductase**, interfering with DNA synthesis and cell proliferation.
- While it has immunosuppressive effects, its primary mechanism in inhibiting purine synthesis is not de novo synthesis in the same manner as mycophenolate mofetil.
*Prednisone*
- **Prednisone** is a **corticosteroid** that exerts its immunosuppressive effects through broad anti-inflammatory actions, genomic and non-genomic effects, affecting the function of various immune cells.
- It does not specifically target **de novo purine synthesis** as its primary mechanism of immunosuppression.
*Cyclophosphamide*
- **Cyclophosphamide** is an **alkylating agent** that cross-links DNA strands, leading to cell cycle arrest and apoptosis, particularly in rapidly dividing cells like lymphocytes.
- While it is a potent immunosuppressant affecting both B and T cells, its mechanism does not involve the inhibition of **de novo purine synthesis**.
Immunosuppressive Agents Indian Medical PG Question 5: A lesion was seen on the face of a 42 year old patient as shown below. Which of the following would be ideal management for this condition?
- A. Topical retinoids
- B. Oral steroids
- C. Start on MDT for leprosy
- D. Start on ATT (Correct Answer)
Immunosuppressive Agents Explanation: ***Start on ATT***
- The presented image shows a **gummy lesion** on the face, which is characteristic of **tuberculosis cutis colliquativa**, a form of cutaneous tuberculosis.
- **Anti-tubercular therapy (ATT)** is the primary and most effective treatment for all forms of tuberculosis, including cutaneous manifestations.
*Topical retinoids*
- Topical retinoids are primarily used for **acne vulgaris** and certain **disorders of keratinization** and are not indicated for infectious granulomatous conditions.
- They work by **regulating cell growth and differentiation**, which is not the mechanism required to treat tuberculosis.
*Oral steroids*
- Oral steroids are **immunosuppressive** and generally contraindicated in active infections like tuberculosis, as they can worsen the disease.
- While they might be used short-term in some inflammatory skin conditions, they would **not address the underlying tuberculous infection**.
*Start on MDT for leprosy*
- **Multi-drug therapy (MDT)** is the standard treatment for leprosy, which also presents with skin lesions and nerve involvement.
- However, the image shows a **single, nodular, ulcerated lesion** more typical of cutaneous tuberculosis rather than the varied forms of leprosy (macular, papular, nodular lesions, or nerve thickening).
Immunosuppressive Agents Indian Medical PG Question 6: A patient presents with the skin lesions shown in the image. All of the following are routinely indicated for the treatment of this condition EXCEPT:
- A. Rituximab (Correct Answer)
- B. Topical vitamin D
- C. Cyclosporine
- D. Acitretin
Immunosuppressive Agents Explanation: ***Rituximab***
- The image displays **plaque psoriasis**, characterized by erythematous plaques with silvery scales. Rituximab, an anti-CD20 monoclonal antibody, targets B-cells and is primarily used in conditions like **lymphoma, leukemia, and rheumatoid arthritis**, not typically for psoriasis.
- While some off-label uses or investigational studies might explore its role, it is **not routinely indicated** for the treatment of psoriasis.
*Topical vitamin D*
- **Topical vitamin D analogs** (e.g., calcipotriene, calcitriol) are a common first-line treatment for mild to moderate plaque psoriasis. They work by **inhibiting keratinocyte proliferation** and promoting their differentiation.
- These agents are often used alone or in combination with topical corticosteroids to reduce inflammation and scaling.
*Cyclosporine*
- **Cyclosporine** is a calcineurin inhibitor used as a systemic treatment for severe psoriasis, especially in cases that are refractory to topical therapies or phototherapy.
- It works by **suppressing the immune system**, thereby reducing the inflammation and rapid cell turnover seen in psoriasis.
*Acitretin*
- **Acitretin** is an oral retinoid indicated for severe psoriasis, particularly **pustular and erythrodermic psoriasis**, and in some cases of chronic plaque psoriasis.
- It normalizes epidermal cell growth and differentiation, effective for extensive or difficult-to-treat forms of the disease.
Immunosuppressive Agents Indian Medical PG Question 7: A patient developed fixed drug eruptions after taking certain medications. Which of the following drugs is known to cause these skin lesions?
- A. Phenolphthalein
- B. Aspirin
- C. Dapsone
- D. All of the above (Correct Answer)
Immunosuppressive Agents Explanation: **Explanation:**
**Fixed Drug Eruption (FDE)** is a unique type of cutaneous drug reaction characterized by the recurrence of a lesion (usually a dusky red or violaceous macule) at the **exact same anatomical site** every time the offending drug is ingested. This occurs due to the persistence of **CD8+ memory T-cells** in the basal keratinocytes at the site of the lesion.
**Why Option D is correct:**
All three drugs listed are classic and high-yield triggers for FDE:
* **Phenolphthalein:** Historically the most common cause (found in older laxatives).
* **Aspirin (NSAIDs):** A very frequent trigger in clinical practice.
* **Dapsone (Sulfonamides):** Sulfonamides are among the most common drug classes associated with FDE.
**Analysis of Options:**
* **Phenolphthalein:** Often presents as "bullous" FDE.
* **Aspirin:** Along with other NSAIDs (like Ibuprofen and Naproxen), it is a leading cause of multi-focal FDE.
* **Dapsone:** As a sulfone, it shares cross-reactivity patterns and is a well-documented cause.
**High-Yield Clinical Pearls for NEET-PG:**
1. **Most Common Site:** The **glans penis** is the most common site for FDE, followed by the lips and palms.
2. **Commonest Causes (Overall):** NSAIDs, Sulfonamides (Cotrimoxazole), Tetracyclines, and Anticonvulsants.
3. **Clinical Feature:** Lesions often leave behind **post-inflammatory hyperpigmentation (PIH)** after healing.
4. **Refractory Period:** After an eruption, there is a brief refractory period where the drug may not cause a reaction.
5. **Diagnosis:** Primarily clinical; however, a **Patch Test** performed at the site of the previous lesion (not on the back) can confirm the offending agent.
Immunosuppressive Agents Indian Medical PG Question 8: Dapsone is used in which of the following conditions?
- A. Dermatitis herpetiformis (Correct Answer)
- B. Pityriasis rosacea
- C. Contact dermatitis
- D. Oculocutaneous albinism
Immunosuppressive Agents Explanation: **Explanation:**
**Dapsone (Diaminodiphenyl sulfone)** is the drug of choice for **Dermatitis Herpetiformis (DH)**. DH is an autoimmune blistering disorder characterized by IgA deposits at the dermal papillae, leading to intense pruritus and neutrophilic infiltration. Dapsone works by inhibiting the enzyme myeloperoxidase and preventing the chemotaxis of neutrophils to the skin, providing rapid symptomatic relief (often within 24–48 hours).
**Analysis of Options:**
* **A. Dermatitis Herpetiformis:** Correct. It is the primary indication for Dapsone in dermatology.
* **B. Pityriasis Rosea:** This is a self-limiting inflammatory condition (likely viral/HHV-6,7). Treatment is supportive (antihistamines, topical steroids); Dapsone has no role.
* **C. Contact Dermatitis:** This is a Type IV hypersensitivity reaction. Management involves allergen avoidance and topical or systemic corticosteroids.
* **D. Oculocutaneous Albinism:** This is a genetic disorder of melanin synthesis. There is no pharmacological "cure"; management focuses on photoprotection and monitoring for skin cancers.
**High-Yield Clinical Pearls for NEET-PG:**
* **Mechanism of Action:** Antifolate (inhibits dihydropteroate synthase) and anti-inflammatory (inhibits neutrophil recruitment).
* **Other Indications:** Leprosy (part of MDT), Pemphigoid, Subcorneal Pustular Dermatosis (Sneddon-Wilkinson disease), and Brown Recluse spider bites.
* **Mandatory Pre-screening:** Always check **G6PD levels** before starting Dapsone to prevent severe **hemolytic anemia**.
* **Side Effects:** Dose-dependent hemolysis, methemoglobinemia (presents as cyanosis), and the "Dapsone Syndrome" (fever, malaise, exfoliative dermatitis, and hepatitis).
Immunosuppressive Agents Indian Medical PG Question 9: Which of the following monoclonal antibodies is used in the treatment of atopic dermatitis?
- A. Ipilimumab
- B. Dupilumab (Correct Answer)
- C. Durvalumab
- D. Reslizumab
Immunosuppressive Agents Explanation: **Explanation:**
**1. Why Dupilumab is Correct:**
Dupilumab is a fully human monoclonal antibody that targets the **interleukin-4 receptor alpha (IL-4Rα) subunit**. By binding to this subunit, it inhibits the signaling of both **IL-4 and IL-13**. These cytokines are the key drivers of **Type 2 (Th2) inflammation**, which is the primary pathophysiological mechanism in atopic dermatitis. It is currently the first-line systemic biologic approved for moderate-to-severe atopic dermatitis unresponsive to topical therapies.
**2. Why the Other Options are Incorrect:**
* **Ipilimumab:** A checkpoint inhibitor that targets **CTLA-4**. It is used in the treatment of advanced melanoma and renal cell carcinoma.
* **Durvalumab:** A checkpoint inhibitor that targets **PD-L1**. It is primarily used in the treatment of non-small cell lung cancer (NSCLC) and bladder cancer.
* **Reslizumab:** An interleukin-5 (**IL-5**) antagonist. It is used as add-on maintenance treatment for severe eosinophilic asthma, not atopic dermatitis.
**3. High-Yield Clinical Pearls for NEET-PG:**
* **Mechanism:** Dual inhibitor of IL-4 and IL-13.
* **Common Side Effect:** The most characteristic side effect of Dupilumab is **allergic conjunctivitis** and blepharitis.
* **Other Indications:** It is also FDA-approved for moderate-to-severe asthma (eosinophilic phenotype) and chronic rhinosinusitis with nasal polyposis.
* **Memory Aid:** "Dupi" stops the "D"ermatitis by blocking the "4" and "13" (IL-4/13).
Immunosuppressive Agents Indian Medical PG Question 10: All of the following statements are true regarding warfarin toxicity (skin necrosis) except?
- A. Skin necrosis occurs during initiation of therapy.
- B. Most common sites are buttocks and abdomen. (Correct Answer)
- C. Decreased quantity of protein C.
- D. Decreased incidence of adverse effects if therapy with LMWH is started.
Immunosuppressive Agents Explanation: **Explanation:**
Warfarin-induced skin necrosis (WISN) is a rare but severe complication occurring in approximately 0.01% to 0.1% of patients treated with vitamin K antagonists.
**Why Option B is the correct answer (The False Statement):**
While the buttocks and abdomen are common sites, the **most common sites** for warfarin necrosis are areas with **high subcutaneous fat content**, specifically the **breasts** (in females), followed by the thighs and buttocks. The statement in Option B is considered the "except" because it overlooks the breast as the primary site of predilection.
**Analysis of Other Options:**
* **Option A:** True. Necrosis typically occurs **3 to 10 days after initiation** of therapy, often due to a large loading dose.
* **Option C:** True. Warfarin inhibits Vitamin K-dependent factors (II, VII, IX, X) and anticoagulant proteins (C and S). **Protein C has a shorter half-life** (6 hours) compared to clotting factors. This creates a transient "prothrombotic window" where natural anticoagulants are depleted while procoagulant factors are still active, leading to microvascular thrombosis.
* **Option D:** True. Starting **Low Molecular Weight Heparin (LMWH)** as a "bridge" provides immediate anticoagulation, preventing the thrombotic complications during the initial drop in Protein C levels.
**Clinical Pearls for NEET-PG:**
* **Risk Factor:** Underlying **Protein C deficiency** is the most significant risk factor.
* **Clinical Presentation:** Sudden onset of painful, erythematous, or purpuric lesions that rapidly progress to **hemorrhagic bullae and eschar**.
* **Management:** Immediate discontinuation of Warfarin, administration of **Vitamin K**, and starting **Heparin** or Protein C concentrates.
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