Immunosuppressive Agents — MCQs
All these drugs are known to exacerbate psoriasis, except:
All of the following are used in systemic therapy of psoriasis except
Which of the following anesthetic agent can cause adrenocortical suppression?
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 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 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 patient developed fixed drug eruptions after taking certain medications. Which of the following drugs is known to cause these skin lesions?
Which of the following is a topical vitamin D analogue?
Which drug is used for intralesional injection in keloids?
Dapsone is used in which of the following conditions?
Immunosuppressive Agents Indian Medical PG Practice Questions and MCQs
Question 1: All these drugs are known to exacerbate psoriasis, except:
- A. Beta blocker
- B. Hydroxychloroquine
- C. Ciclosporin (Correct Answer)
- D. Lithium
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.
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
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.
Question 3: Which of the following anesthetic agent can cause adrenocortical suppression?
- A. Halothane
- B. Ketamine
- C. Etomidate (Correct Answer)
- D. Propofol
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.
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
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**.
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)
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).
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
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.
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)
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.
Question 8: Which of the following is a topical vitamin D analogue?
- A. Cholecalciferol
- B. Doxercalciferol
- C. Calcipotriol (Correct Answer)
- D. Paricalcitol
Explanation: **Explanation:** **Calcipotriol** is a synthetic analog of **1,25-dihydroxyvitamin D3 (Calcitriol)**. In dermatology, it is primarily used as a first-line topical treatment for **Psoriasis vulgaris**. Its mechanism of action involves binding to intracellular vitamin D receptors (VDR), leading to the inhibition of keratinocyte proliferation and the induction of keratinocyte differentiation. It also possesses anti-inflammatory properties by inhibiting T-cell activation. **Analysis of Options:** * **Calcipotriol (Correct):** It is specifically designed for topical use. It is as effective as potent topical corticosteroids but has a better safety profile for long-term maintenance, as it does not cause skin atrophy. * **Cholecalciferol (Option A):** This is Vitamin D3, typically administered orally as a nutritional supplement to treat Vitamin D deficiency. * **Doxercalciferol (Option B) & Paricalcitol (Option D):** These are synthetic Vitamin D analogs administered **systemically** (oral or IV). They are primarily used in the management of secondary hyperparathyroidism in patients with chronic kidney disease (CKD). **High-Yield Clinical Pearls for NEET-PG:** * **Combination Therapy:** Calcipotriol is frequently combined with **Betamethasone dipropionate** (e.g., Daivobet) for synergistic effects in psoriasis. * **Side Effects:** The most common side effect is local skin irritation. Systemic hypercalcemia is rare unless the dose exceeds **100g per week**. * **Contraindication:** It should not be applied to the face (due to irritation) and is generally avoided in patients with pre-existing hypercalcemia. * **Other Topical Analogs:** Tacalcitol and Maxacalcitol are other topical analogs used globally.
Question 9: Which drug is used for intralesional injection in keloids?
- A. Prednisolone
- B. Triamcinolone (Correct Answer)
- C. Androgen
- D. Hydrocortisone
Explanation: **Explanation:** **Triamcinolone acetonide (TAC)** is the gold standard and most commonly used drug for the intralesional treatment of keloids and hypertrophic scars. **Why Triamcinolone is the Correct Answer:** Triamcinolone is a potent, intermediate-acting synthetic corticosteroid. It works by: 1. **Inhibiting Fibroblasts:** It reduces the proliferation of fibroblasts and the synthesis of collagen. 2. **Anti-inflammatory Action:** It decreases the release of inflammatory mediators (like TGF-β) that drive excessive scarring. 3. **Increasing Collagenase:** It reduces levels of alpha-2-macroglobulin, which normally inhibits collagenase, thereby promoting the breakdown of existing collagen. The concentration typically used is **10–40 mg/mL**, injected directly into the mid-dermis of the lesion. **Analysis of Incorrect Options:** * **A & D (Prednisolone & Hydrocortisone):** These are shorter-acting corticosteroids with lower potency. They are highly soluble and rapidly absorbed into the systemic circulation, making them ineffective for maintaining the sustained local concentration required to break down dense keloidal tissue. * **C (Androgen):** Androgens have no role in the treatment of keloids; in fact, hormonal fluctuations (like puberty or pregnancy) are sometimes associated with keloid exacerbation. **High-Yield Clinical Pearls for NEET-PG:** * **Side Effects:** The most common side effects of intralesional TAC include **dermal atrophy, telangiectasia, and hypopigmentation** at the injection site. * **Combination Therapy:** For resistant keloids, TAC is often combined with **5-Fluorouracil (5-FU)** to improve efficacy and reduce atrophy. * **Cryosurgery:** Performing cryotherapy immediately before injection (the "cryo-insult" technique) softens the keloid, making the injection easier and more effective.
Question 10: Dapsone is used in which of the following conditions?
- A. Dermatitis herpetiformis (Correct Answer)
- B. Pityriasis rosacea
- C. Contact dermatitis
- D. Oculocutaneous albinism
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).
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