Rheumatology and Immunology Practice Questions

Q: What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Increase in titre of anti-dsDNA. In Systemic Lupus Erythematosus (SLE), monitoring disease activity is crucial for managing flares. The correct answer is **Option A: Increase in titre of anti-dsDNA**. ### **Why Anti-dsDNA is the Correct Answer** Anti-dsDNA antibodies are highly specific for SLE and their levels correlate directly with disease activity. A rising titre often precedes a clinical flare, particularly **Lupus Nephritis** [1]. When these antibodies increase, they form immune complexes that activate the complement system, leading to a simultaneous **decrease in C3 and C4 levels** [1]. This "rising anti-dsDNA and falling complement" pattern is the classic laboratory hallmark of an SLE flare. ### **Why Other Options are Incorrect** * **B. Increase in titre of ANA:** ANA is the best screening test (high sensitivity) but is useless for monitoring flares [1]. Once positive, the titre does not reliably correlate with disease severity or activity. * **C. Increase in anti-Sm:** Anti-Smith antibodies are the most specific for SLE, but like ANA, their levels remain relatively constant and do not fluctuate with disease activity [1]. * **D. Elevation of ESR:** While ESR is often raised in SLE, it is a non-specific marker of inflammation. It can be elevated due to infections or other co-morbidities, making it less reliable than anti-dsDNA for confirming a lupus-specific flare [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **Most Sensitive Test:** ANA (95-98%) [1]. * **Most Specific Test:** Anti-Sm (followed by anti-dsDNA) [1]. * **Drug-Induced Lupus:** Anti-Histone antibodies are the marker of choice. * **Neonatal Lupus/Sjogren’s:** Associated with Anti-Ro (SS-A) and Anti-La (SS-B) [1]. * **Active Nephritis Profile:** ↑ Anti-dsDNA + ↓ Complement (C3, C4) [1].

Q: Which is NOT a feature of polymyositis?

Gottron's rash. **Explanation:** The correct answer is **Gottron’s rash** because it is a pathognomonic cutaneous feature of **Dermatomyositis**, not Polymyositis [1]. While both conditions share similar patterns of muscle involvement, Polymyositis (PM) is strictly an inflammatory myopathy without primary skin manifestations. **Analysis of Options:** * **Gottron's rash (Correct):** These are erythematous, scaly eruptions over the dorsal aspects of the MCP and IP joints [1], [2]. Along with the Heliotrope rash, it distinguishes Dermatomyositis from Polymyositis [2]. * **Proximal muscle involvement:** This is the hallmark of PM. Patients typically present with symmetrical weakness of the shoulder and pelvic girdles (e.g., difficulty climbing stairs or combing hair) [1]. * **Pharyngeal muscle involvement:** In severe cases of PM, the striated muscles of the upper esophagus and pharynx are involved, leading to dysphagia and an increased risk of aspiration pneumonia [1]. * **Pain in limbs:** While the primary symptom is weakness, approximately 25-50% of patients with PM report muscle tenderness or myalgia during the acute phase [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Immunopathology:** PM is mediated by **CD8+ T-cells** (endomysial inflammation), whereas Dermatomyositis is mediated by **CD4+ T-cells and B-cells** (perifascicular atrophy). * **Antibodies:** **Anti-Jo-1** is the most common myositis-specific antibody and is strongly associated with **Interstitial Lung Disease (ILD)** and "Mechanic's hands" [1]. * **Malignancy:** Both are associated with increased cancer risk, but the risk is significantly higher in Dermatomyositis [2]. * **Diagnosis:** Gold standard is a **Muscle Biopsy**; initial screening involves elevated **CPK levels** [2].

Q: Which among the following is true about Caplan's syndrome?

Pneumoconiosis with rheumatoid arthritis. **Explanation:** **Caplan’s Syndrome** (also known as Rheumatoid Pneumoconiosis) is a clinical entity characterized by the development of specific pulmonary nodules in patients with **Pneumoconiosis** (most commonly Coal Worker's Pneumoconiosis, but also Silicosis or Asbestosis) [1] who also have **Rheumatoid Arthritis (RA)** [2]. 1. **Why Option D is Correct:** The syndrome represents an exaggerated inflammatory response in the lungs. In patients with a rheumatoid diathesis, the inhalation of inorganic dust triggers the formation of multiple, well-defined "Caplan nodules" (0.5 to 5 cm in diameter). These nodules are histologically similar to subcutaneous rheumatoid nodules but occur within the lung parenchyma, typically on a background of mild pneumoconiosis [1]. 2. **Why Other Options are Incorrect:** * **Option A:** While pneumoconiosis (like Silicosis) can cause hilar lymphadenopathy (e.g., "egg-shell calcification"), this is a feature of the primary disease, not Caplan’s syndrome [1]. * **Option B:** Congestive cardiac failure is not a defining component of this syndrome, though chronic lung disease can eventually lead to Cor Pulmonale. * **Option C:** There is no specific association between Caplan’s syndrome and HIV. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Look for multiple, bilateral, peripheral "crop-like" nodules that may appear suddenly. * **Serology:** Patients are typically **Rheumatoid Factor (RF) positive**. * **Timing:** Pulmonary nodules can appear before, during, or after the onset of clinical arthritis [2]. * **Differential:** Must be distinguished from **Erasmus Syndrome**, which is the association of Silicosis with Systemic Sclerosis (Scleroderma).

Q: What is the most common pattern of joint involvement in psoriatic arthropathy?

Asymmetrical inflammatory oligoarthritis. **Explanation:** Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy associated with psoriasis, classified under seronegative spondyloarthropathies [1]. **1. Why Option D is Correct:** Historically and classically, **Asymmetrical inflammatory oligoarthritis** is considered the most common pattern of involvement (occurring in approximately 70% of cases). It typically involves a few large joints (like the knee) along with one or two small joints of the fingers or toes, often presenting with a characteristic "sausage digit" (dactylitis). **2. Analysis of Incorrect Options:** * **Option A (Psoriatic spondylitis):** This involves the axial skeleton (sacroiliitis and spondylitis). While high-yield, it occurs in only about 5–20% of patients and is rarely the presenting feature [1]. * **Option B (Arthritis mutilans):** This is the most severe but **least common** form (<5%). It involves extensive bone resorption (osteolysis) leading to "telescoping fingers" [1] and the "pencil-in-cup" appearance on X-ray. * **Option C (Symmetrical polyarthritis):** This pattern mimics Rheumatoid Arthritis (RA) but is Rheumatoid Factor (RF) negative. While some modern studies suggest its prevalence is rising, traditional teaching and standard textbooks (like Harrison’s) still prioritize asymmetrical oligoarthritis as the most frequent pattern for examination purposes. **3. NEET-PG High-Yield Pearls:** * **DIP Joint Involvement:** PsA is one of the few inflammatory remains that involves the Distal Interphalangeal (DIP) joints [1]. * **Nail Changes:** Pitting, onycholysis, and hyperkeratosis are strongly associated with the development of PsA [1]. * **Radiology:** Look for the **"Pencil-in-cup" deformity** and "Gull-wing" appearance. * **HLA Association:** Strongly linked with **HLA-B27** (especially in the spondylitis variant) [1].

Q: What are the common manifestations in Takayasu arteritis?

All of the above. **Explanation:** Takayasu arteritis (TA), often referred to as **"Pulseless Disease,"** is a chronic, large-vessel vasculitis that primarily involves the aorta and its major branches [2]. It is most common in young women (usually <40 years). **Why Option D is Correct:** The disease progresses through an inflammatory phase to a "burnt-out" fibrotic phase, leading to stenosis, occlusion, or aneurysmal dilation of vessels. * **Loss of pulses (Option A):** This is a hallmark feature. Narrowing or occlusion of the subclavian or brachial arteries leads to absent or weak peripheral pulses and significant blood pressure discrepancies between the arms. * **Renal hypertension (Option B):** Involvement of the renal arteries (Renal Artery Stenosis) is common, leading to renovascular hypertension due to activation of the Renin-Angiotensin-Aldosterone System (RAAS) [1]. * **Coronary involvement (Option C):** While less common than aortic involvement, the coronary ostia can be affected by the inflammatory process, leading to stenosis, dilation, or aneurysm formation, which may result in myocardial infarction. **Clinical Pearls for NEET-PG:** * **Classification:** It is a **Large Vessel Vasculitis** (alongside Giant Cell Arteritis) [2]. * **Diagnosis:** Often suggested by a **bruit** over the carotid or subclavian arteries and an elevated ESR/CRP during the active phase. * **Gold Standard Investigation:** **CT Angiography or MR Angiography** (shows "wall thickening" or "string of pearls" appearance) [1]. * **Treatment:** Glucocorticoids are the first-line treatment; methotrexate or azathioprine are used as steroid-sparing agents. Surgical bypass or angioplasty may be required for severe stenosis.

Q: A 30-year-old male presents with pain in his lower extremities, aggravated by walking, and a history of cigarette smoking. In this patient, the prevalence of which histocompatibility antigen is increased?

HLA-B5. ### Explanation **Diagnosis: Buerger’s Disease (Thromboangiitis Obliterans)** The clinical presentation of a young male smoker with lower extremity pain aggravated by walking (claudication) is classic for **Buerger’s Disease**. This is a non-atherosclerotic, segmental, inflammatory disease that most commonly affects small and medium-sized arteries and veins in the extremities [1]. **1. Why HLA-B5 is correct:** Genetic predisposition plays a significant role in Buerger’s disease. Studies have consistently shown an increased prevalence of **HLA-B5** (specifically the B51 subtype) and **HLA-A9** in patients with this condition. The immune-mediated nature of the disease is further evidenced by the presence of anti-endothelial cell antibodies and sensitivity to tobacco antigens. **2. Analysis of Incorrect Options:** * **HLA-B8:** Associated with several autoimmune conditions, most notably **Myasthenia Gravis** and **Celiac disease**. * **HLA-DR2:** Strongly linked to **Multiple Sclerosis**, Goodpasture syndrome, and Systemic Lupus Erythematosus (SLE). * **HLA-DR3:** Associated with **Type 1 Diabetes Mellitus**, SLE, and Dermatitis herpetiformis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of Buerger’s:** Claudication (distal), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign) due to the occlusion of distal vessels [1]. * **Definitive Management:** Absolute **smoking cessation** is the only way to halt disease progression and prevent amputation. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis).

Q: A 14-year-old girl, upon exposure to cold, experiences pallor of her extremities followed by pain and cyanosis. In later stages of life, to which condition is she most prone?

Scleroderma. The clinical presentation described—pallor (ischemia), followed by cyanosis (hypoxia) and pain/rubor (reperfusion) upon cold exposure—is the classic **triphasic response of Raynaud’s Phenomenon**. **Why Scleroderma is the Correct Answer:** Raynaud’s phenomenon (RP) is the initial sign in approximately **95% of patients with Systemic Sclerosis (Scleroderma)**. In many cases, especially in the limited cutaneous subtype (CREST syndrome), RP can precede other systemic symptoms (like skin thickening or esophageal dysmotility) by years or even decades [1]. While RP can be primary (idiopathic), its appearance in a young female warrants screening for secondary causes, of which Scleroderma is the most strongly associated. **Analysis of Incorrect Options:** * **Systemic Lupus Erythematosus (SLE):** While RP occurs in about 30% of SLE patients, it is rarely the presenting or most dominant feature compared to Scleroderma [2]. * **Rheumatoid Arthritis:** RP is uncommon in RA; the primary pathology involves inflammatory synovitis rather than the severe digital vasculopathy seen in Scleroderma. * **Dermatomyositis:** Though RP can occur in inflammatory myositis (especially in Anti-synthetase syndrome), the association is significantly weaker than with Scleroderma. **High-Yield Clinical Pearls for NEET-PG:** * **Primary vs. Secondary RP:** Primary Raynaud’s (Raynaud’s Disease) is usually symmetric and lacks tissue gangrene. Secondary Raynaud’s (Raynaud’s Phenomenon) is often asymmetric and associated with digital pits or ulcers. * **Nailfold Capillaroscopy:** This is the best initial test to distinguish primary from secondary RP. "Megacapillaries" or dropout areas suggest an underlying connective tissue disorder like Scleroderma [1]. * **Drug of Choice:** Calcium Channel Blockers (e.g., **Nifedipine**) are the first-line treatment for Raynaud’s Phenomenon.

Q: Cavitary lesions are characteristically seen in which of the following conditions?

Wegener's granulomatosis. **Explanation:** The correct answer is **Wegener's granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA). **1. Why Wegener’s Granulomatosis is correct:** GPA is a small-vessel vasculitis characterized by a triad of necrotizing granulomas of the upper/lower respiratory tract, systemic vasculitis, and glomerulonephritis [1]. Pulmonary involvement is seen in 90% of patients. The hallmark radiological finding is **multiple, bilateral, nodular infiltrates** that frequently undergo central necrosis, leading to **thick-walled cavitary lesions** [1]. This is driven by the underlying granulomatous inflammation and tissue necrosis. **2. Why the other options are incorrect:** * **SLE:** Pulmonary involvement typically presents as pleuritis, pleural effusion, or acute lupus pneumonitis [2]. Cavitation is extremely rare and usually suggests a secondary infection rather than the primary disease. * **Classical Polyarteritis Nodosa (PAN):** A key diagnostic feature of classical PAN is that it **spares the lungs** [1]. If pulmonary vessels are involved, the diagnosis shifts toward GPA or Eosinophilic Granulomatosis with Polyangiitis (EGPA). * **Tuberculosis (TB):** While TB is a classic cause of cavitary lesions, the question asks for the characteristic presentation among systemic immunological/vasculitic conditions. In the context of rheumatology and multisystem vasculitis, GPA is the definitive answer. **Clinical Pearls for NEET-PG:** * **Serology:** GPA is strongly associated with **c-ANCA (PR3-ANCA)**. * **Upper Airway:** Look for "Saddle nose deformity" or chronic sinusitis in the clinical stem [1]. * **Renal:** Causes Pauci-immune Crescentic Glomerulonephritis. * **Differential for Cavitary Lung Lesions (Mnemonic: CAVITY):** **C**ancer (SCC), **A**utoimmune (GPA), **V**ascular (Septic emboli), **I**nfection (TB, Fungal), **T**rauma, **Y**outh (CPAM).

Question 1

Features of systemic sclerosis include all of the following, EXCEPT:

Accepted Answer

More common in young patients

Answer

Calcinosis

Answer

Sclerodactyly

Answer

Hyperpigmentation (Melanin deposition)

Question 2

What is the laboratory evidence of a flare in Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Increase in titre of anti-dsDNA

Answer

Increase in titre of ANA

Answer

Increase in anti-Sm

Answer

Elevation of ESR

Question 3

A 45-year-old woman has experienced worsening arthritis of her hands and feet for the past 15 years. On physical examination, there are marked deformities of the hands and feet, with ulnar deviation of the hands and swan-neck deformities of the fingers. Laboratory studies show an elevated level of rheumatoid factor. CBC shows hemoglobin, 11.6 g/dL; hematocrit, 34.8%; MCV, 87 mm3; platelet count, 268,000/ mm3; and WBC count, 6800/ mm3. There is a normal serum haptoglobin level, serum iron concentration of 20 mg/ dL, total iron-binding capacity of 195 mg/dL, percent saturation of 10.2, and serum ferritin concentration of 317 ng/mL. No fibrin split products are detected. The reticulocyte concentration is 1.1%. What is the most likely mechanism underlying this patient's hematologic abnormalities?

Accepted Answer

Inadequate usage of stored iron

Answer

Autoantibodies against RBC membranes

Answer

Impaired synthesis of beta-globin chains

Answer

Sequestration of RBCs in splenic sinusoids

Question 4

Which is NOT a feature of polymyositis?

Accepted Answer

Gottron's rash

Answer

Pharyngeal muscle involvement

Answer

Proximal muscle involvement

Answer

Pain in limbs

Question 5

Which among the following is true about Caplan's syndrome?

Accepted Answer

Pneumoconiosis with rheumatoid arthritis

Answer

Pneumoconiosis with lymphadenopathy

Answer

Pneumoconiosis with congestive cardiac failure

Answer

Pneumoconiosis with HIV

Question 6

What is the most common pattern of joint involvement in psoriatic arthropathy?

Accepted Answer

Asymmetrical inflammatory oligoarthritis

Answer

Psoriatic spondylitis

Answer

Arthritis mutilans

Answer

Symmetrical polyarthritis

Question 7

What are the common manifestations in Takayasu arteritis?

Accepted Answer

All of the above

Answer

Loss of pulses

Answer

Renal hypertension

Answer

Coronary aneurysm or its dilation

Question 8

A 30-year-old male presents with pain in his lower extremities, aggravated by walking, and a history of cigarette smoking. In this patient, the prevalence of which histocompatibility antigen is increased?

Accepted Answer

HLA-B5

Answer

HLA-B8

Answer

HLA-DR2

Answer

HLA-DR3

Question 9

A 14-year-old girl, upon exposure to cold, experiences pallor of her extremities followed by pain and cyanosis. In later stages of life, to which condition is she most prone?

Accepted Answer

Scleroderma

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Rheumatoid Arthritis

Answer

Dermatomyositis

Question 10

Cavitary lesions are characteristically seen in which of the following conditions?

Accepted Answer

Wegener's granulomatosis

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Classical Polyarteritis Nodosa (PAN)

Answer

Tuberculosis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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