Rheumatology and Immunology Practice Questions

Q: Which of the following statements is NOT true regarding rheumatic pleural effusion?

Glucose greater than 50. ### Explanation Rheumatoid Pleural Effusion is a classic example of an **exudative effusion** with unique biochemical markers. The hallmark of this condition is an **extremely low glucose level**, typically **less than 30 mg/dL** (and often <15 mg/dL). #### Why Option C is the Correct Answer (The "False" Statement) In rheumatoid pleurisy, glucose levels are characteristically very low due to a combination of active consumption by the inflamed pleura and a block in the transport of glucose from the blood into the pleural space. Therefore, the statement "Glucose greater than 50" is incorrect. #### Analysis of Other Options * **A. pH less than 7.2:** True. Rheumatoid effusions are highly acidic, often with a pH below 7.0, reflecting intense local inflammation [1]. * **B. LDH greater than 700:** True. These effusions are characterized by very high Lactate Dehydrogenase (LDH) levels, frequently exceeding 700–1000 IU/L, indicating significant cellular turnover and pleural inflammation. * **D. ADA level >50 U/L:** True. While Adenosine Deaminase (ADA) is a classic marker for Tuberculosis, it is also frequently elevated (often >50 U/L) in Rheumatoid Arthritis and Empyema, which can lead to diagnostic confusion. #### NEET-PG High-Yield Pearls * **Low Glucose Triad:** The three main causes of pleural fluid glucose <30 mg/dL are **Rheumatoid Arthritis**, **Empyema**, and **Malignancy**. * **Complement Levels:** Rheumatoid effusions typically show **low complement levels** (C3, C4, and CH50) compared to serum levels. * **Cytology:** Look for "gritty" appearance or "tadpole cells" (elongated macrophages) on cytology. * **Epidemiology:** Interestingly, while RA is more common in women, rheumatoid pleural effusions are more common in **older men** with rheumatoid nodules [2].

Q: All may be associated with Sicca syndrome except?

Midline granuloma. **Explanation:** **Sicca Syndrome** (Primary Sjögren’s Syndrome) is a chronic autoimmune disorder characterized by lymphocytic infiltration of exocrine glands, primarily leading to xerophthalmia (dry eyes) and xerostomia (dry mouth). It can occur alone or secondary to other connective tissue diseases. **Why Midline Granuloma is the correct answer:** Midline granuloma (often referring to **Lethal Midline Granuloma** or Granulomatosis with Polyangiitis) is a destructive inflammatory process involving the nasal passage and paranasal sinuses. It is characterized by necrotizing granulomas and vasculitis. It does not typically involve the lymphocytic infiltration of salivary or lacrimal glands and is therefore not associated with Sicca syndrome. **Analysis of other options:** * **Scleroderma (Systemic Sclerosis):** Frequently associated with secondary Sjögren’s syndrome due to glandular fibrosis and autoimmune destruction. * **Rheumatoid Arthritis (RA):** This is the **most common** autoimmune disease associated with secondary Sjögren’s syndrome (occurring in ~30% of RA patients) [1]. * **Lymphadenopathy:** Patients with Sjögren’s syndrome often exhibit lymph node enlargement. Crucially, they have a **40-fold increased risk** of developing B-cell Non-Hodgkin Lymphoma (MALToma), making lymphadenopathy a significant clinical finding to monitor. **High-Yield Clinical Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are the hallmark markers. * **Diagnosis:** Schirmer’s test (measures tear production) and Lip biopsy (showing focal lymphocytic sialadenitis) are gold standards. * **Extraglandular manifestation:** Raynaud’s phenomenon and cutaneous vasculitis are common. * **Highest Risk:** Sjögren’s syndrome carries the highest risk of lymphoma among all autoimmune diseases.

Q: Which of the following is NOT a feature of seronegative spondyloarthropathy?

Symmetrical Polyarthritis. **Explanation:** Seronegative spondyloarthropathies (SpA) are a group of inflammatory diseases (including Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, and Enteropathic Arthritis) characterized by the absence of Rheumatoid Factor (RF) and distinct clinical features [1]. **Why "Symmetrical Polyarthritis" is the correct answer:** Seronegative spondyloarthropathies typically present as **Asymmetrical Oligoarthritis** (involving <5 joints, often in the lower limbs) [1]. In contrast, **Symmetrical Polyarthritis** is the hallmark of Rheumatoid Arthritis [2]. While Psoriatic Arthritis can occasionally present with a symmetrical pattern, it is not a defining or universal feature of the SpA group. **Analysis of Incorrect Options:** * **A. Strong association with HLA B27:** This is a classic feature. HLA-B27 is most strongly associated with Ankylosing Spondylitis (>90% of cases) and is a key diagnostic marker for the entire group [1]. * **B. Negative Rheumatoid Factor:** By definition, these conditions are "seronegative," meaning RF and Anti-CCP antibodies are typically absent [1]. * **D. Enthesitis:** This is a pathognomonic feature of SpA. It refers to inflammation at the site where tendons or ligaments insert into bone (e.g., Achilles tendonitis or plantar fasciitis) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Common Features (PEAR):** **P**soriatic arthritis, **E**nteropathic arthritis, **A**nkylosing spondylitis, **R**eactive arthritis. * **Axial Involvement:** Sacroiliitis and spondylitis (bamboo spine) are characteristic [1]. * **Extra-articular manifestations:** Acute anterior uveitis is the most common extra-articular finding [1]. * **Dactylitis:** "Sausage digits" are frequently seen, especially in Psoriatic and Reactive arthritis.

Q: Which of the following statements about fibromyalgia is true?

SPECT studies have shown reduced blood flow to the thalamus. Explanation: Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances [1]. It is considered a disorder of central pain processing (central sensitization). Why Option D is Correct: Functional neuroimaging studies, including SPECT (Single-Photon Emission Computed Toxicity) and functional MRI, have consistently demonstrated altered pain processing in the brain [1]. Specifically, patients with fibromyalgia show reduced regional cerebral blood flow (hypoperfusion) in the thalamus and the caudate nucleus [1]. Since the thalamus acts as the "gatekeeper" for sensory input, this dysfunction contributes to the lowered pain threshold (allodynia). Analysis of Incorrect Options: * Option A: Fibromyalgia is significantly more common in females (ratio approx. 7:1 to 9:1), typically presenting between ages 20 and 50. * Option B: Sleep studies (Polysomnography/EEG) show a characteristic disruption in Stage 4 Non-REM sleep, specifically the "alpha-delta sleep" pattern (intrusion of alpha waves into deep delta sleep), rather than REM sleep disruption [1]. * Option C: Fibromyalgia is associated with a blunted (decreased) cortisol response to stress due to mild secondary adrenal insufficiency or hypothalamic-pituitary-adrenal (HPA) axis dysregulation [1], not an increased response. High-Yield Clinical Pearls for NEET-PG: * Diagnosis: Primarily clinical [1]. The 2010/2016 ACR criteria focus on the Widespread Pain Index (WPI) and Symptom Severity (SS) scale, moving away from the older "11 of 18 tender points" requirement. * Lab Findings: All inflammatory markers (ESR, CRP) and muscle enzymes (CPK) are characteristically normal [2]. * Management: First-line treatment involves patient education and aerobic exercise [2]. Pharmacotherapy includes Amitriptyline (TCA), Duloxetine (SNRI), or Pregabalin (Gabapentinoid).

Q: Sausage digit is seen in which of the following conditions?

Psoriatic arthritis. **Explanation:** **Sausage digit**, clinically known as **Dactylitis**, is the hallmark feature of **Sero-negative Spondyloarthropathies (SpA)**. It represents diffuse swelling of an entire finger or toe due to inflammation of the small joints and, more importantly, the surrounding tendons and their sheaths (tenosynovitis) [1]. **Why Psoriatic Arthritis (PsA) is correct:** PsA is the most common cause of dactylitis, occurring in approximately 30–50% of patients. Unlike the localized joint swelling seen in Rheumatoid Arthritis, dactylitis involves the entire digit, giving it a "sausage-like" appearance [1]. It is a key diagnostic criterion in the CASPAR criteria for PsA. **Why other options are incorrect:** * **Rheumatoid Arthritis (RA):** RA typically causes symmetrical, localized swelling of the MCP and PIP joints (spindle-shaped fingers) [2]. It does not involve the entire digit or the tendon sheaths in a way that produces dactylitis. * **Juvenile Idiopathic Arthritis (JIA):** While some subtypes (like Enthesitis-related JIA) can show dactylitis, it is not the classic or defining feature compared to PsA. * **Enteropathic Arthritis:** While it is a Spondyloarthropathy, dactylitis is much rarer here than in PsA or Reactive Arthritis [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **Differential Diagnosis of Dactylitis:** Psoriatic Arthritis (most common), Reactive Arthritis (Reiter’s), Ankylosing Spondylitis, Sickle Cell Anemia (Hand-foot syndrome), and Sarcoidosis. 2. **Radiology:** Look for the "Pencil-in-cup" deformity in PsA [1]. 3. **Nail Changes:** Pitting of nails and onycholysis in a patient with joint pain strongly suggests PsA [1]. 4. **Symmetry:** PsA is typically asymmetric, whereas RA is symmetric [2].

Q: Etanercept is a biological disease-modifying agent used in the management of rheumatoid arthritis. What is its mechanism of action?

TNF alpha blockade. **Explanation:** **Etanercept** is a biological Disease-Modifying Antirheumatic Drug (bDMARD) used primarily in Rheumatoid Arthritis (RA), Ankylosing Spondylitis, and Psoriasis [1]. 1. **Mechanism of Action (Option A):** Etanercept is a **soluble TNF-receptor fusion protein**. It consists of two extracellular domains of the human p75 TNF receptor linked to the Fc portion of human IgG1 [1]. It acts as a "decoy receptor," binding to both **TNF-α and TNF-β** (lymphotoxin-α) in the circulation, thereby preventing them from interacting with cell-bound receptors. This neutralizes the pro-inflammatory cascade driven by TNF [4]. 2. **Analysis of Incorrect Options:** * **Option B (COX2 inhibition):** This is the mechanism of NSAIDs like Celecoxib. They provide symptomatic relief but do not modify the disease course [3]. * **Option C (IL-6 inhibition):** This describes **Tocilizumab** and Sarilumab. While also used in RA, they target a different cytokine pathway [4]. * **Option D (Mast cell stabilization):** This is the mechanism of drugs like Cromolyn sodium, used in asthma and allergic rhinitis, not RA. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** "Etanercept **S**epts (Accepts) TNF." (It is a receptor, unlike Infliximab/Adalimumab which are monoclonal antibodies) [1]. * **Screening:** Before starting any TNF inhibitor, patients **must** be screened for **Latent Tuberculosis** (via TST or IGRA) and Hepatitis B, as these drugs can cause reactivation. * **Side Effects:** Increased risk of serious infections [1], injection site reactions, and potential worsening of Heart Failure. * **Drug of Choice:** While Methotrexate remains the initial DMARD of choice [2], Etanercept is often added in refractory cases [1].

Question 1

Which of the following statements is NOT true regarding rheumatic pleural effusion?

Accepted Answer

Glucose greater than 50

Answer

pH less than 7.2

Answer

LDH greater than 700

Answer

ADH level >50mg/dl

Question 2

All may be associated with Sicca syndrome except?

Accepted Answer

Midline granuloma

Answer

Scleroderma

Answer

Rheumatoid arthritis

Answer

Lymphadenopathy

Question 3

Which of the following is NOT a feature of seronegative spondyloarthropathy?

Accepted Answer

Symmetrical Polyarthritis

Answer

Strong association with HLA B27

Answer

Negative Rheumatoid Factor

Answer

Enthesitis

Question 4

Which of the following statements about fibromyalgia is true?

Accepted Answer

SPECT studies have shown reduced blood flow to the thalamus

Answer

More common in males

Answer

Sleep EEG studies have shown disruption in REM sleep

Answer

Increased cortisol response to stress

Question 5

A 14-year-old girl on exposure to cold has pallor of extremities followed by pain and cyanosis. In later life, she is prone to develop which of the following conditions?

Accepted Answer

Scleroderma

Answer

Systemic lupus erythematosus

Answer

Rheumatoid arthritis

Answer

Histiocytosis

Question 6

Churg-Strauss syndrome involves which of the following, except?

Accepted Answer

Heart

Answer

Lungs

Answer

Kidneys

Answer

Small blood vessels

Question 7

Mononeuritis multiplex is a major presenting feature of which of the following conditions?

Accepted Answer

Systemic necrotising vasculitis

Answer

Wagner's granulomatosis

Answer

Hypersensitivity vasculitis

Answer

Mucocutaneous lymphnode syndrome

Question 8

A 28-year-old man presents with symptoms of frequent bowel movements, crampy abdominal pain, and the passage of mucus. There is no history of bloody diarrhea, but recently, he developed joint discomfort in his hands, knees, and back. On examination, he is thin, and his abdomen is soft with voluntary guarding in the left lower quadrant. His joints are not actively inflamed and there is an asymmetric distribution. Which of the following is the most likely diagnosis?

Accepted Answer

Ulcerative colitis

Answer

Lymphoma of the bowel

Answer

Amyloid infiltration

Answer

Chronic pancreatitis

Question 9

Sausage digit is seen in which of the following conditions?

Accepted Answer

Psoriatic arthritis

Answer

Rheumatoid arthritis

Answer

Juvenile idiopathic arthritis

Answer

Enteropathic arthritis

Question 10

Etanercept is a biological disease-modifying agent used in the management of rheumatoid arthritis. What is its mechanism of action?

Accepted Answer

TNF alpha blockade

Answer

COX2 inhibition

Answer

IL 6 inhibition

Answer

Stabilization of mast cells

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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