Rheumatology and Immunology Practice Questions

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

7. **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.

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

Bamboo sign. **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.

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

Systemic manifestations. 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].

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

Systemic Lupus Erythematosus (SLE). 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.

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

Osteoarthritis. 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].

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

Elevated anti-streptolysin-O. 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).

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

Female sex. 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].

Question 1

What is the most common cranial nerve involved in sarcoidosis?

Accepted Answer

7

Answer

3

Answer

5

Answer

8

Question 2

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

Accepted Answer

High serum uric acid levels may not be present.

Answer

Allopurinol is used in the acute control of gout.

Answer

Colchicine acts slowly.

Answer

Colchicine causes gastrointestinal disturbances.

Question 3

Which of the following is NOT true about psoriatic arthritis?

Accepted Answer

Bamboo sign

Answer

CASPER Criteria

Answer

Involves DIP joints

Answer

Pencil-in-cup deformity

Question 4

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

Accepted Answer

Systemic manifestations

Answer

Dry eyes

Answer

Dry mouth

Answer

Parotid gland enlargement

Question 5

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?

Accepted Answer

Schirmer test and measurement of autoantibodies

Answer

Lip biopsy

Answer

IgG antibody to mumps virus

Answer

Use of corticosteroids

Question 6

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

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Classic Polyarteritis Nodosa (PAN)

Answer

Kawasaki disease

Answer

Buerger disease

Question 7

Mixed connective tissue disease includes all the following findings except?

Accepted Answer

Osteoarthritis

Answer

Polymyositis

Answer

Rheumatoid arthritis

Answer

Systemic sclerosis

Question 8

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

Accepted Answer

Elevated anti-streptolysin-O

Answer

Carditis

Answer

Polyarthritis

Answer

Erythema marginatum

Question 9

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

Accepted Answer

Decreased thyroid autoantibodies

Answer

Decreased testosterone

Answer

Decreased luteinizing hormone

Answer

Decreased dehydroepiandrosterone

Question 10

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

Accepted Answer

Female sex

Answer

Alcohol consumption

Answer

Hyperlipidemia

Answer

Hypertension

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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