Rheumatology and Immunology — MCQs

A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On exam, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. What is the next step in evaluation?

Q96Medium

All of the following are examples of medium vessel vasculitis EXCEPT?

Q97Easy

Mixed connective tissue disease includes all the following findings except?

Q98Easy

Which of the following is NOT a major manifestation of rheumatic fever and rheumatic heart disease?

Q99Medium

Hormonal abnormalities in men and post-menopausal women suffering from rheumatoid arthritis include the following, except?

Q100Easy

Which of the following is NOT a risk factor associated with the development of gout?

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 91: What is the most common cranial nerve involved in sarcoidosis?

A. 3
B. 5
C. 7 (Correct Answer)
D. 8

Explanation: **Explanation:** **Sarcoidosis** is a multisystem granulomatous disease that affects the nervous system in approximately 5–10% of cases (Neurosarcoidosis). **Why Option C is Correct:** The **Facial Nerve (CN VII)** is the most common cranial nerve involved in sarcoidosis [1]. It typically presents as a lower motor neuron facial palsy, which can be unilateral or bilateral. In fact, sarcoidosis is one of the most common causes of **bilateral facial nerve palsy**. The involvement is often transient and may occur in the setting of **Heerfordt’s Syndrome** (Uveoparotid fever), characterized by the triad of: 1. Parotid enlargement 2. Anterior uveitis 3. Facial nerve palsy **Why Incorrect Options are Wrong:** * **Option A (CN 3):** While the oculomotor nerve can be involved due to basal meningitis, it is significantly less common than CN VII. * **Option B (CN 5):** Trigeminal involvement is rare in sarcoidosis; sensory loss in the face is more commonly associated with connective tissue diseases like Systemic Sclerosis. * **Option D (CN 8):** The vestibulocochlear nerve is the second most common cranial nerve involved (causing hearing loss or vertigo), but it still trails behind the facial nerve in frequency. **High-Yield Clinical Pearls for NEET-PG:** * **Lofgren’s Syndrome:** Erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthritis (Good prognosis) [1]. * **Diagnosis:** Non-caseating granulomas on biopsy; elevated Serum ACE levels (useful for monitoring, not diagnostic). * **Chest X-ray:** Stage I is Bilateral Hilar Lymphadenopathy (BHL) alone [1]. * **Treatment:** Corticosteroids are the first-line treatment for symptomatic neurosarcoidosis.

Question 92: A patient presents with severe pain and swelling in the great toe. Which of the following statements regarding gout are true?

A. Allopurinol is used in the acute control of gout.
B. Colchicine acts slowly.
C. Colchicine causes gastrointestinal disturbances.
D. High serum uric acid levels may not be present. (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. High serum uric acid levels may not be present.** In clinical practice, serum uric acid levels can be **normal or even low** during an acute attack of gout [1]. This occurs because inflammatory cytokines (like IL-6) are uricosuric, increasing renal excretion of uric acid. Additionally, uric acid crystals precipitate out of the blood into the joint space, lowering circulating levels. Therefore, a normal uric acid level during an acute episode does not rule out gout. **Analysis of Incorrect Options:** * **A. Allopurinol is used in the acute control of gout:** This is incorrect. Allopurinol is a xanthine oxidase inhibitor used for **chronic management** (prophylaxis) [2]. Starting it during an acute attack can worsen the inflammation by causing rapid shifts in serum urate levels, leading to the mobilization of crystals from tissues [2]. * **B. Colchicine acts slowly:** This is incorrect. Colchicine is a fast-acting anti-inflammatory agent specifically used for acute flares. It works by inhibiting microtubule polymerization and leukocyte chemotaxis. * **C. Colchicine causes gastrointestinal disturbances:** While this statement is clinically true (diarrhea is a hallmark side effect), it is generally considered a **disadvantage or side effect** rather than a defining therapeutic characteristic in the context of this specific question's comparison. However, in many competitive exams, Option D is the "most correct" high-yield physiological fact being tested. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Demonstration of **negatively birefringent, needle-shaped crystals** under polarized light microscopy. * **Acute Management:** NSAIDs (first-line), Colchicine, or Corticosteroids. * **Chronic Management:** Wait **2 weeks after** an acute attack subsides before starting Allopurinol or Febuxostat [2]. * **Dietary Triggers:** High-purine foods (red meat, seafood), alcohol (especially beer), and fructose-sweetened beverages [3].

Question 93: Which of the following is NOT true about psoriatic arthritis?

A. CASPER Criteria
B. Involves DIP joints
C. Pencil-in-cup deformity
D. Bamboo sign (Correct Answer)

Explanation: **Explanation:** Psoriatic Arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis, belonging to the group of **Seronegative Spondyloarthropathies**. [1] **Why "Bamboo Sign" is the correct answer:** The **Bamboo Spine** (syndesmophyte formation leading to vertebral fusion) is the classic radiological hallmark of **Ankylosing Spondylitis (AS)**, not Psoriatic Arthritis. [1] While PsA can involve the spine (spondylitis), it typically presents with asymmetric, coarse, and non-marginal syndesmophytes, unlike the symmetric, marginal syndesmophytes seen in AS. [1] **Analysis of incorrect options:** * **A. CASPAR Criteria:** The **Cl**assification **A**criteria for **Ps**oriatic **Ar**thritis (CASPAR) are the current diagnostic standard. A patient must have inflammatory arthritis plus 3 points from categories including current psoriasis, history of psoriasis, dactylitis, nail dystrophy, and negative Rheumatoid Factor. * **B. Involves DIP joints:** Unlike Rheumatoid Arthritis (which spares the DIP), PsA characteristically involves the **Distal Interphalangeal (DIP) joints**. [1] This is often associated with adjacent nail changes (pitting, onycholysis). [1] * **C. Pencil-in-cup deformity:** This is the classic radiographic feature of **Arthritis Mutilans** (a severe subtype of PsA). [1] It occurs due to periarticular osteolysis and bone resorption, where the proximal phalanx is whittled down (pencil) and the distal bone becomes hollowed out (cup). **NEET-PG High-Yield Pearls:** * **Dactylitis:** "Sausage digits" (diffuse swelling of a finger/toe) is a hallmark of PsA. * **HLA Association:** Strongly associated with **HLA-B27** (especially in axial disease). [1] * **Radiology:** Look for "Telescoping" of digits and "Opera glass hand" in severe cases. [1] * **Treatment:** TNF-alpha inhibitors (e.g., Etanercept, Adalimumab) and IL-17 inhibitors (e.g., Secukinumab) are highly effective.

Question 94: All of the following may be associated with Sjogren syndrome, except?

A. Dry eyes
B. Dry mouth
C. Parotid gland enlargement
D. Systemic manifestations (Correct Answer)

Explanation: The question asks for the feature **not** associated with Sjögren Syndrome (SS) among the given options. However, there appears to be a conceptual nuance in the provided answer key. In clinical practice, Sjögren Syndrome is a systemic autoimmune disease; however, the "classic triad" focuses on sicca symptoms. **1. Why "Systemic Manifestations" is the marked answer:** While Sjögren Syndrome *can* have extraglandular (systemic) features in about 30-40% of patients (such as vasculitis, interstitial lung disease, or lymphoma), the **hallmark** and most defining features are localized to the exocrine glands. In the context of basic undergraduate/PG entrance definitions, the syndrome is primarily characterized by the destruction of lacrimal and salivary glands. If a question implies "what defines the syndrome," the localized sicca symptoms are the primary features, whereas systemic involvement is a complication rather than a universal requirement. **2. Analysis of Incorrect Options:** * **A. Dry Eyes (Xerophthalmia):** A core component of the disease caused by lymphocytic infiltration of the lacrimal glands, leading to keratoconjunctivitis sicca [1]. * **B. Dry Mouth (Xerostomia):** A core component caused by the destruction of salivary glands, leading to difficulty swallowing dry food and increased dental caries. * **C. Parotid Gland Enlargement:** Seen in approximately 30-50% of patients. It is typically bilateral, painless, and episodic, caused by intense lymphocytic infiltration. **Clinical Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are highly specific [1]. * **Diagnosis:** Schirmer’s test (for tear production) and Lip biopsy (showing focal lymphocytic sialadenitis) are gold standards. * **Malignancy Risk:** Patients have a **40-fold increased risk of B-cell Lymphoma** (MALToma). * **Association:** Often associated with RA (Secondary Sjögren’s) [1].

Question 95: A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On exam, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. What is the next step in evaluation?

A. Lip biopsy
B. Schirmer test and measurement of autoantibodies (Correct Answer)
C. IgG antibody to mumps virus
D. Use of corticosteroids

Explanation: ### Explanation **Clinical Diagnosis: Sjögren’s Syndrome** The patient presents with the classic triad of **xerostomia** (dry mouth), **keratoconjunctivitis sicca** (dry eyes/gritty sensation), and **bilateral parotid gland enlargement**. The difficulty in speaking for extended periods is a direct consequence of reduced salivary flow. **1. Why Option B is Correct:** The diagnosis of Sjögren’s Syndrome requires objective evidence of both ocular/oral dryness and systemic autoimmunity. * **Schirmer test:** Quantifies tear production (positive if ≤5 mm of moisture on filter paper after 5 minutes). * **Autoantibodies:** Testing for **Anti-Ro (SS-A)** and **Anti-La (SS-B)** is the initial serological step [3]. These are highly specific markers included in the ACR/EULAR classification criteria. **2. Why Other Options are Incorrect:** * **A. Lip Biopsy:** While a minor salivary gland biopsy (showing focal lymphocytic sialadenitis) is the "gold standard" for diagnosis, it is **invasive**. It is typically reserved for cases where serology is negative but clinical suspicion remains high. * **C. IgG antibody to mumps:** Mumps causes acute, painful parotitis, usually in children. It does not cause chronic sicca symptoms or the "gritty" eye sensation seen here. * **D. Use of corticosteroids:** This is a treatment, not a diagnostic step. Furthermore, steroids are generally reserved for systemic/extraglandular manifestations (e.g., vasculitis); they do not effectively restore salivary or lacrimal gland function. **3. NEET-PG High-Yield Pearls:** * **Primary vs. Secondary:** Primary Sjögren’s occurs alone; Secondary is most commonly associated with **Rheumatoid Arthritis** [4]. * **Malignancy Risk:** Patients have a **40-fold increased risk** of developing **B-cell MALT Lymphoma** (look for persistent parotid swelling or loss of autoantibodies). * **Extraglandular features:** Most common is **Arthralgia/Arthritis** [1]; others include Raynaud’s phenomenon and Interstitial Lung Disease. * **Treatment:** Primarily symptomatic (artificial tears, pilocarpine/cevimeline for secretagogues) [2].

Question 96: All of the following are examples of medium vessel vasculitis EXCEPT?

A. Classic Polyarteritis Nodosa (PAN)
B. Kawasaki disease
C. Buerger disease
D. Systemic Lupus Erythematosus (SLE) (Correct Answer)

Explanation: The classification of vasculitis is primarily based on the size of the predominant vessel involved (Chapel Hill Consensus Conference) [1]. **Why SLE is the correct answer:** Systemic Lupus Erythematosus (SLE) is not a primary vasculitis. While it can cause secondary vasculitis, it is typically categorized as a **small vessel vasculitis** (specifically involving capillaries and post-capillary venules) when it occurs. SLE is primarily a multi-system autoimmune disease characterized by immune complex deposition (Type III hypersensitivity), rather than a primary medium-vessel pathology. **Analysis of incorrect options (Medium Vessel Vasculitides):** * **Classic Polyarteritis Nodosa (PAN):** The prototype of medium vessel vasculitis. It involves necrotizing inflammation of medium and small muscular arteries, notably sparing the lungs. It is strongly associated with Hepatitis B. * **Kawasaki Disease:** A leading cause of acquired heart disease in children. It is a medium vessel vasculitis with a predilection for the **coronary arteries**, often presenting with "strawberry tongue" and mucocutaneous lymph node syndrome. * **Buerger Disease (Thromboangiitis Obliterans):** A segmental, inflammatory, non-atherosclerotic occlusive disease of small and medium-sized arteries and veins in the distal extremities, highly associated with heavy tobacco use. **High-Yield Clinical Pearls for NEET-PG:** * **Large Vessel:** Giant Cell Arteritis, Takayasu Arteritis. * **Medium Vessel:** PAN, Kawasaki, Buerger disease. * **Small Vessel (ANCA +ve):** Granulomatosis with Polyangiitis (Wegener's), Microscopic Polyangiitis, Churg-Strauss [2]. * **Small Vessel (Immune Complex):** Henoch-Schönlein Purpura (IgA vasculitis), Cryoglobulinemic vasculitis [2]. * **Key Distinction:** PAN does **not** involve capillaries or venules and is **ANCA-negative**, distinguishing it from microscopic polyangiitis.

Question 97: Mixed connective tissue disease includes all the following findings except?

A. Polymyositis
B. Rheumatoid arthritis
C. Osteoarthritis (Correct Answer)
D. Systemic sclerosis

Explanation: Mixed Connective Tissue Disease (MCTD), also known as **Sharp’s Syndrome**, is an overlap syndrome characterized by clinical features of several distinct autoimmune diseases [2]. The hallmark of MCTD is the presence of high titers of **anti-U1 RNP antibodies** [2]. **Why Osteoarthritis is the correct answer:** Osteoarthritis is a **degenerative** joint disease caused by "wear and tear" of articular cartilage. It is not an autoimmune or systemic inflammatory condition. Therefore, it is not part of the overlap spectrum that defines MCTD. **Analysis of other options (Components of MCTD):** MCTD typically presents as a combination of features from the following three systemic autoimmune rheumatic diseases (SARDs): * **Systemic Sclerosis (Scleroderma):** Often manifests as Raynaud’s phenomenon (the most common initial symptom) and sclerodactyly [2]. * **Polymyositis:** Presents as proximal muscle weakness and elevated muscle enzymes [2]. * **Systemic Lupus Erythematosus (SLE):** Features include malar rash, photosensitivity, or serositis [2]. * **Rheumatoid Arthritis:** While not always listed in the primary triad, many patients develop a deforming, erosive polyarthritis identical to RA [2]. **Clinical Pearls for NEET-PG:** * **Serology:** High titer **anti-U1 RNP** is mandatory for diagnosis [1], [2]. Anti-dsDNA and anti-Sm are usually absent (if present, consider SLE) [1]. * **Most common initial feature:** Raynaud’s phenomenon [2]. * **Most common cause of death:** Pulmonary Hypertension (unlike SLE, where it is often renal failure or infection) [2]. * **Hand findings:** "Puffy hands" or swollen fingers are a very characteristic early sign [2].

Question 98: Which of the following is NOT a major manifestation of rheumatic fever and rheumatic heart disease?

A. Carditis
B. Elevated anti-streptolysin-O (Correct Answer)
C. Polyarthritis
D. Erythema marginatum

Explanation: This question tests your knowledge of the **Jones Criteria**, which is the clinical standard for diagnosing the first episode of Acute Rheumatic Fever (ARF).### Why "Elevated anti-streptolysin-O" is the Correct Answer In the Jones Criteria, manifestations are divided into **Major** and **Minor** categories. **Elevated anti-streptolysin-O (ASO) titer** is neither a major nor a minor manifestation; rather, it is a **mandatory requirement** (evidence of a preceding Group A Streptococcal infection) needed to support the diagnosis [1]. While essential for diagnosis, it does not count as a "Major manifestation."### Explanation of Incorrect Options (Major Criteria) The Major manifestations are remembered by the mnemonic **J♥NES**: * **Carditis (Option A):** Occurs in 50-70% of cases. It is the only manifestation that leads to chronic disability (Rheumatic Heart Disease) [1]. * **Polyarthritis (Option C):** Specifically a "migratory" large joint polyarthritis. It is the most common major manifestation. * **Erythema Marginatum (Option D):** A classic, non-pruritic, pink macular rash with serpiginous borders, typically found on the trunk and limbs (never the face). * *Note: The other two major criteria are **Sydenham’s Chorea** and **Subcutaneous Nodules** [1].* ### High-Yield Clinical Pearls for NEET-PG * **Minor Criteria:** Include fever, polyarthralgia, prolonged PR interval on ECG, and elevated inflammatory markers (ESR/CRP). * **Diagnosis Rule:** 2 Major OR 1 Major + 2 Minor criteria, PLUS evidence of preceding Strep infection (ASO titer, positive throat culture, or Rapid Strep Antigen test) [1]. * **Exception:** Sydenham’s Chorea or indolent carditis can be diagnostic of ARF even without evidence of a preceding Strep infection [1]. * **Most Common Valve Involved:** Mitral valve (Mitral Regurgitation in acute phase; Mitral Stenosis in chronic phase).

Question 99: Hormonal abnormalities in men and post-menopausal women suffering from rheumatoid arthritis include the following, except?

A. Decreased testosterone
B. Decreased luteinizing hormone
C. Decreased dehydroepiandrosterone
D. Decreased thyroid autoantibodies (Correct Answer)

Explanation: In Rheumatoid Arthritis (RA), the chronic inflammatory milieu significantly alters the hypothalamic-pituitary-gonadal (HPG) and hypothalamic-pituitary-adrenal (HPA) axes. [1] **Why Option D is the Correct Answer:** Rheumatoid arthritis is an autoimmune disorder often associated with other organ-specific autoimmune conditions. Patients with RA have a **higher prevalence of thyroid autoantibodies** (such as anti-TPO and anti-TG) compared to the general population. Therefore, "decreased thyroid autoantibodies" is incorrect, as these markers are typically **elevated** or more frequent in RA patients. **Explanation of Incorrect Options:** * **A & C (Decreased Testosterone and DHEA):** Chronic inflammation leads to the suppression of the HPG axis. Pro-inflammatory cytokines (like TNF-α and IL-6) inhibit the synthesis of androgens. [1] Men and post-menopausal women with RA frequently show low levels of testosterone and DHEA/DHEA-S, which may further exacerbate the inflammatory state since androgens have immunomodulatory (anti-inflammatory) effects. * **B (Decreased Luteinizing Hormone):** While one might expect LH to rise in response to low testosterone (primary hypogonadism), the chronic illness in RA often causes "hypogonadotropic hypogonadism." The inflammatory cytokines suppress the pituitary's secretion of LH, leading to inappropriately low or "decreased" LH levels relative to the low androgen state. **High-Yield Clinical Pearls for NEET-PG:** * **Androgen Deficiency:** Low testosterone in men is a recognized risk factor for developing RA and correlates with increased disease activity. * **The "Pregnancy Paradox":** RA symptoms often improve during pregnancy due to high estrogen/progesterone levels but flare postpartum. * **Thyroid Link:** Always screen RA patients for thyroid dysfunction, as **Hashimoto’s thyroiditis** is the most common co-existing autoimmune endocrine disorder. * **Hyperprolactinemia:** Occasionally, RA patients may show elevated prolactin, which is considered a pro-inflammatory hormone. [2]

Question 100: Which of the following is NOT a risk factor associated with the development of gout?

A. Female sex (Correct Answer)
B. Alcohol consumption
C. Hyperlipidemia
D. Hypertension

Explanation: The correct answer is **A. Female sex**. In the epidemiology of gout, male sex is a well-established risk factor. Estrogen has a **uricosuric effect** (it promotes the excretion of uric acid by the kidneys), which keeps serum urate levels lower in premenopausal women. Consequently, gout is significantly more common in men and postmenopausal women. **Analysis of Options:** * **Alcohol consumption (Option B):** This is a major risk factor. Alcohol (especially beer) increases urate production through purine metabolism and decreases urate excretion by increasing lactic acid levels, which competes with uric acid for renal excretion. * **Hyperlipidemia (Option C):** Gout is strongly associated with **Metabolic Syndrome**. Hypertriglyceridemia is frequently seen in gout patients, and the underlying insulin resistance associated with dyslipidemia reduces renal uric acid clearance [1]. * **Hypertension (Option D):** Hypertension is an independent risk factor for gout. Furthermore, many antihypertensive medications (specifically **Thiazide and Loop diuretics**) decrease urate excretion, precipitating hyperuricemia [3]. **High-Yield Clinical Pearls for NEET-PG:** * **The "Estrogen Protection":** Gout is rare in premenopausal women; if present, look for underlying renal disease or genetic enzymatic defects. * **Drug-Induced Gout:** Remember the mnemonic **CANT** (Cyclosporine, Alcohol, Nicotinic acid, Thiazides) for drugs that cause hyperuricemia [3]. * **Losartan Exception:** Unlike other ARBs or antihypertensives, **Losartan** has uricosuric properties and is the preferred agent for hypertensive patients with gout. * **Gold Standard Diagnosis:** Identification of **negatively birefringent, needle-shaped crystals** under polarized light microscopy [2].

Practice by Chapter

Rheumatoid Arthritis

Practice Questions

Spondyloarthropathies

Practice Questions

Systemic Lupus Erythematosus

Practice Questions

Vasculitis Syndromes

Practice Questions

Scleroderma and Related Disorders

Practice Questions

Inflammatory Myopathies

Practice Questions

Crystal Arthropathies

Practice Questions

Osteoarthritis

Practice Questions

Primary Immunodeficiency Disorders

Practice Questions

Autoinflammatory Syndromes

Practice Questions

Sjögren's Syndrome

Practice Questions

Antiphospholipid Syndrome

Practice Questions

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