Rheumatology and Immunology — MCQs

A 25-year-old woman presents with concerns about systemic lupus erythematosus, citing intermittent oral ulcers and right knee pain. She has no significant past medical history and uses only occasional ibuprofen. Physical examination reveals no alopecia, skin rash, or joint swelling. Her blood work shows a positive ANA at a titer of 1:40, with no other abnormalities. Which of the following statements is true?

Q128Easy

Which of the following is a feature of osteoarthritis?

Q129Easy

SS-A (Ro) and SS-B (La) antibodies found in Sjogren syndrome are targeted against which cellular component?

Q130Medium

Which of the following statements regarding an acute attack of gouty arthritis is EXCEPT?

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 121: All of the following are true about temporal arteritis except?

A. Polymyalgia rheumatica
B. Anemia
C. Low ESR (Correct Answer)
D. Sudden blindness

Explanation: Explanation: Temporal Arteritis (Giant Cell Arteritis) is a large-vessel vasculitis that primarily affects the extracranial branches of the carotid artery [1]. Why "Low ESR" is the correct answer: In Temporal Arteritis, the Erythrocyte Sedimentation Rate (ESR) is characteristically markedly elevated, often exceeding 100 mm/hr. A low or normal ESR is extremely rare in active disease [1]. C-reactive protein (CRP) is also typically elevated. Analysis of other options: * Polymyalgia Rheumatica (PMR): Approximately 40–50% of patients with Temporal Arteritis also have PMR, characterized by proximal muscle pain and stiffness (shoulders and hips) [1]. * Anemia: Chronic inflammation in vasculitis leads to Anemia of Chronic Disease (normocytic, normochromic), which is a common systemic finding in these patients [1]. * Sudden Blindness: This is the most dreaded complication. It occurs due to Anterior Ischemic Optic Neuropathy (AION) caused by occlusion of the posterior ciliary arteries. It is a medical emergency requiring immediate high-dose corticosteroids [1]. High-Yield Clinical Pearls for NEET-PG: * Demographics: Almost exclusively occurs in patients >50 years of age. * Gold Standard Diagnosis: Temporal artery biopsy (look for "skip lesions"; hence a long segment must be biopsied) [1]. * Histopathology: Granulomatous inflammation with multinucleated giant cells and fragmentation of the internal elastic lamina [1]. * Treatment: Do not wait for biopsy results; start High-dose Glucocorticoids immediately if clinical suspicion is high to prevent permanent vision loss [1].

Question 122: Diffuse cutaneous systemic sclerosis is characterized by which of the following?

A. Early pulmonary fibrosis (Correct Answer)
B. Raynaud's phenomenon
C. Calcinosis cutis
D. Better long-term prognosis

Explanation: **Explanation:** Systemic Sclerosis (SSc) is divided into two main subsets: **Diffuse Cutaneous (dcSSc)** and **Limited Cutaneous (lcSSc)**. The distinction is based on the extent of skin involvement and the timing of internal organ complications. [1] **Why Option A is Correct:** In **Diffuse Cutaneous SSc**, skin thickening involves the proximal limbs and trunk. Crucially, it is characterized by the **early onset of internal organ involvement**, most notably **Interstitial Lung Disease (Pulmonary Fibrosis)** and scleroderma renal crisis. [2] Pulmonary fibrosis often develops within the first 5 years of disease onset and is a leading cause of mortality in these patients. [3] **Why Other Options are Incorrect:** * **B. Raynaud’s Phenomenon:** While present in both types, it typically precedes skin changes by years in *limited* SSc. In *diffuse* SSc, Raynaud’s often occurs concurrently with or shortly before skin thickening. * **C. Calcinosis Cutis:** This is a classic feature of the **CREST syndrome**, which is the hallmark of **Limited Cutaneous SSc**. While it can occur in dcSSc, it is far more characteristic of the limited subtype. * **D. Better long-term prognosis:** This is incorrect. dcSSc has a **worse prognosis** compared to lcSSc due to rapid skin progression and early, severe visceral involvement (lung, heart, and kidney). **NEET-PG High-Yield Pearls:** * **Antibody Association:** dcSSc is linked to **Anti-Scl-70 (Anti-topoisomerase I)**; lcSSc is linked to **Anti-centromere antibodies**. * **Pulmonary Hypertension:** More commonly an isolated, late complication in *Limited* SSc. * **Renal Crisis:** Most common in *Diffuse* SSc; treated with **ACE inhibitors** (even if creatinine is elevated).

Question 123: Perioral and periorbital skin lesions are seen in which condition?

A. Idiopathic thrombocytopenic purpura
B. Cutaneous vasculitis
C. Primary systemic amyloidosis (pinch purpura) (Correct Answer)
D. Lupus erythematosus

Explanation: **Explanation:** The correct answer is **Primary Systemic Amyloidosis (AL Amyloidosis)**. In primary systemic amyloidosis, there is an extracellular deposition of amyloid fibrils (derived from immunoglobulin light chains) within the skin and blood vessel walls [1]. This leads to increased capillary fragility. Minor trauma or pressure—such as coughing, sneezing, or even gentle rubbing—causes these fragile vessels to rupture, resulting in characteristic **"Pinch Purpura"** (post-traumatic purpura). These lesions are classically found in areas where the skin is thin and lax, most notably the **periorbital** (often called "raccoon eyes") and **perioral** regions. **Analysis of Incorrect Options:** * **Idiopathic Thrombocytopenic Purpura (ITP):** Presents with petechiae and ecchymoses due to low platelet counts, but these are typically generalized (often on the lower limbs) and lack the specific periorbital predilection seen in amyloidosis. * **Cutaneous Vasculitis:** Characterized by **palpable purpura**, usually on the lower extremities. It is an inflammatory process of the vessel walls, unlike the non-inflammatory deposition seen in amyloidosis. * **Lupus Erythematosus:** Systemic Lupus (SLE) typically presents with a malar (butterfly) rash that spares the nasolabial folds. While it can cause vasculitis, it does not typically present with periorbital pinch purpura. **High-Yield NEET-PG Pearls:** * **Macroglossia:** The most common oral manifestation of AL amyloidosis (enlarged, firm tongue). * **Shoulder Pad Sign:** Visible swelling of the shoulder joints due to amyloid infiltration of the synovium. * **Diagnosis:** Apple-green birefringence under polarized light after **Congo Red staining**. * **Biopsy Site:** Abdominal fat pad biopsy is a common initial screening test. [Note: Dermatomyositis may also present with periorbital 'heliotrope' erythema, illustrating the importance of clinical differentiation between purpura and inflammatory erythema] [2].

Question 124: This type of lesion is most commonly seen in which disease?

A. Systemic Lupus Erythematosus (SLE)
B. Gout
C. Marfan syndrome
D. Rheumatoid Arthritis (RA) (Correct Answer)

Explanation: ***Rheumatoid Arthritis (RA)*** - **Rheumatoid nodules** are pathognomonic subcutaneous lesions found in approximately 20-30% of RA patients, typically over **pressure points** like elbows and knuckles. - These firm, non-tender nodules consist of a **central necrotic core** surrounded by **epithelioid cells** and are strongly associated with **positive rheumatoid factor** and severe disease. *Systemic Lupus Erythematosus (SLE)* - Characteristic skin lesions include the **malar rash** (butterfly rash) and **discoid lesions**, not subcutaneous nodules. - **Photosensitive rashes** and **oral ulcers** are more typical dermatological manifestations of SLE. *Gout* - **Tophi** are urate crystal deposits that can occur in chronic gout, but they are typically **chalky white** and located around joints, ears, or tendons. - Tophi develop after years of **hyperuricemia** and are composed of **monosodium urate crystals**, unlike the inflammatory nodules in RA. *Marfan syndrome* - This connective tissue disorder primarily affects the **cardiovascular**, **skeletal**, and **ocular systems** without characteristic skin nodules. - Skin manifestations include **striae distensae** and **hyperextensible skin**, but not subcutaneous nodular lesions.

Question 125: Groton's sign is seen in which of the following conditions?

A. Dermatomyositis (Correct Answer)
B. Systemic Lupus Erythematosus (SLE)
C. Scleroderma
D. Mixed Connective Tissue Disease (MCTD)

Explanation: **Explanation:** **Gottron’s sign** (often referred to as Gottron papules) is a pathognomonic cutaneous manifestation of **Dermatomyositis** [1]. It consists of symmetric, erythematous to violaceous, somewhat scaly patches or papules found over the dorsal aspects of the interphalangeal (IP) and metacarpophalangeal (MCP) joints [1]. The underlying medical concept involves an autoimmune-mediated microvascular injury that manifests as these characteristic skin lesions alongside proximal muscle weakness [2]. **Analysis of Options:** * **Dermatomyositis (Correct):** Gottron’s sign and the Heliotrope rash (periorbital violaceous discoloration) are the hallmark dermatological findings [1]. * **Systemic Lupus Erythematosus (SLE):** While SLE presents with a malar (butterfly) rash, it typically **spares the IP/MCP joints** (interarticular sparing), unlike Dermatomyositis which specifically involves them. * **Scleroderma:** Characterized by skin thickening (sclerodactyly), Raynaud’s phenomenon, and telangiectasia, but not Gottron’s papules. * **MCTD:** This is an overlap syndrome (SLE, Scleroderma, and Polymyositis features) associated with **anti-U1 RNP antibodies**. While it can have features of myositis, Gottron’s sign is specifically diagnostic for Dermatomyositis. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic triad for Dermatomyositis:** Gottron’s papules, Heliotrope rash, and Shawl sign (erythema over shoulders/neck) [1]. * **Mechanic’s Hands:** Hyperkeratotic, fissured skin on the lateral fingers; highly associated with **Anti-Jo-1 antibodies** (Antisynthetase syndrome) [2]. * **Malignancy Risk:** Dermatomyositis in adults is associated with an increased risk of internal malignancies (Ovarian, Lung, Gastric); age-appropriate cancer screening is mandatory [1]. * **Muscle Enzymes:** Elevated Creatine Kinase (CK) and Aldolase are key laboratory findings [1].

Question 126: A 33-year-old woman has experienced episodes of fatigue, pleural effusion, pericardial effusion, carpal tunnel syndrome, and macrocytic anemia. What is the best test for diagnosis?

A. Anti-beta 2 phospholipid antibodies
B. Anti-smith antibody
C. Antinuclear antibody
D. Assay for thyroid hormones (Correct Answer)

Explanation: ### Explanation The clinical presentation of fatigue, serositis (pleural and pericardial effusions), carpal tunnel syndrome, and macrocytic anemia in a young woman is a classic "clinical trap" designed to mimic Systemic Lupus Erythematosus (SLE). However, these features are collectively highly characteristic of **Hypothyroidism** [1]. **1. Why "Assay for Thyroid Hormones" is correct:** * **Serositis:** Hypothyroidism causes increased capillary permeability and decreased lymphatic drainage, leading to protein-rich effusions (pleural/pericardial). * **Carpal Tunnel Syndrome:** Deposition of mucopolysaccharides (glycosaminoglycans) in the flexor retinaculum causes median nerve compression [1]. * **Macrocytic Anemia:** While hypothyroidism can cause normocytic anemia, it is a well-known cause of non-megaloblastic macrocytosis. Additionally, it is frequently associated with Pernicious Anemia (Autoimmune Polyendocrine Syndrome). * **Fatigue:** A hallmark constitutional symptom of low metabolic states [1]. **2. Why the other options are incorrect:** * **Options A, B, and C (Antiphospholipid, Anti-Smith, ANA):** These are markers for SLE. While SLE causes serositis and fatigue, it typically presents with inflammatory markers, cytopenias (usually microcytic or hemolytic anemia), and rashes. It does **not** typically cause carpal tunnel syndrome or non-hemolytic macrocytic anemia. **Clinical Pearls for NEET-PG:** * **The "Great Mimicker":** Hypothyroidism should be a top differential for any patient presenting with unexplained serositis and weight gain. * **Anemia Patterns:** Hypothyroidism is the most common endocrine cause of **macrocytosis**. * **Reversible CTS:** Carpal tunnel syndrome in hypothyroidism is often reversible with thyroxine replacement. * **Woltman Sign:** Look for "delayed relaxation of deep tendon reflexes" in the clinical stem to confirm a thyroid etiology [1].

Question 127: A 25-year-old woman presents with concerns about systemic lupus erythematosus, citing intermittent oral ulcers and right knee pain. She has no significant past medical history and uses only occasional ibuprofen. Physical examination reveals no alopecia, skin rash, or joint swelling. Her blood work shows a positive ANA at a titer of 1:40, with no other abnormalities. Which of the following statements is true?

A. Four diagnostic criteria are required for a diagnosis of systemic lupus erythematosus; this patient has three.
B. Four diagnostic criteria are required for a diagnosis of systemic lupus erythematosus; this patient has two. (Correct Answer)
C. If a urinalysis shows proteinuria, she will meet criteria for systemic lupus erythematosus.
D. The demonstration of a positive ANA alone is adequate to diagnose systemic lupus erythematosus.

Explanation: To diagnose Systemic Lupus Erythematosus (SLE), clinicians typically use the **ACR (American College of Rheumatology)** or **SLICC** criteria. Under the ACR criteria, a patient must meet at least **4 out of 11** criteria (at least one clinical and one immunologic) to be classified as having SLE. ### 1. Why Option B is Correct This patient currently meets only **two** criteria: 1. **Oral Ulcers:** (Clinical) 2. **Positive ANA:** (Immunologic) [1] The reported "knee pain" (arthralgia) does not count as a criterion unless there is objective evidence of **arthritis** (swelling, effusion, or tenderness in two or more peripheral joints) on physical examination. Since her exam was normal, she does not meet the arthritis criterion. ### 2. Analysis of Incorrect Options * **Option A:** Incorrect because the patient only has two criteria (Oral ulcers + ANA). Arthralgia without objective swelling is not a diagnostic criterion. * **Option C:** Proteinuria (>0.5g/day) would add a third criterion (Renal). However, she would still only have three criteria (Ulcers, ANA, Proteinuria), falling short of the four required for a definitive diagnosis. * **Option D:** ANA is highly sensitive (95-99%) but has low specificity [1]. Many healthy individuals (up to 5-10%) have low titers (1:40) [1]. ANA alone is never diagnostic without supporting clinical features. ### 3. NEET-PG High-Yield Pearls * **Most Specific Tests:** Anti-dsDNA and Anti-Smith (Anti-Sm) antibodies [1]. * **Most Sensitive Test:** ANA (Best screening test) [1]. * **Drug-Induced Lupus:** Characterized by **Anti-Histone antibodies**; usually spares the CNS and Kidneys. * **Complement Levels:** Low C3 and C4 levels correlate with disease activity (especially lupus nephritis) [1]. * **EULAR/ACR 2019 Criteria:** Entry criterion is an ANA titer ≥ 1:80; if not present, SLE cannot be diagnosed.

Question 128: Which of the following is a feature of osteoarthritis?

A. Heberden node (Correct Answer)
B. Increased ESR
C. Onycholysis
D. Z deformity

Explanation: **Explanation:** **Osteoarthritis (OA)** is a degenerative joint disease characterized by the progressive loss of articular cartilage and the formation of new bone (osteophytes) at the joint margins [1]. 1. **Heberden Nodes (Correct Answer):** These are palpable bony enlargements (osteophytes) located at the **Distal Interphalangeal (DIP) joints**. They are a hallmark clinical feature of nodal OA [1]. Similar enlargements at the **Proximal Interphalangeal (PIP) joints** are known as **Bouchard nodes** [1]. 2. **Increased ESR (Incorrect):** OA is primarily a non-inflammatory, degenerative condition [1]. Therefore, systemic inflammatory markers like Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) are typically **normal**. An elevated ESR suggests an inflammatory arthritis like Rheumatoid Arthritis (RA) or systemic lupus erythematosus. 3. **Onycholysis (Incorrect):** This refers to the painless separation of the nail from the nail bed. It is a classic dermatological feature of **Psoriatic Arthritis**, not OA. 4. **Z-deformity (Incorrect):** This is a characteristic deformity of the hand seen in **Rheumatoid Arthritis**, consisting of radial deviation at the wrist and ulnar deviation of the digits. **High-Yield Clinical Pearls for NEET-PG:** * **Joint Involvement:** OA characteristically involves the DIP, PIP, and the 1st Carpometacarpal (CMC) joint (squaring of the wrist) [1]. It **spares** the Metacarpophalangeal (MCP) joints, which are typically involved in RA. * **Radiological Hallmarks:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [1]. * **Pain Pattern:** Pain worsens with activity and is relieved by rest (unlike RA, where stiffness improves with activity) [1]. * **Synovial Fluid:** Non-inflammatory (WBC count <2000 cells/mm³).

Question 129: SS-A (Ro) and SS-B (La) antibodies found in Sjogren syndrome are targeted against which cellular component?

A. DNA topoisomerase 1
B. Histones
C. Ribonucleoproteins (Correct Answer)
D. Native DNA

Explanation: **Explanation:** The correct answer is **Ribonucleoproteins**. SS-A (Ro) and SS-B (La) are autoantibodies directed against small cytoplasmic **ribonucleoproteins (RNPs)** [1]. These proteins are complexed with small RNA molecules (Y1-Y5 RNA) and play roles in RNA processing and translation. * **SS-A (Ro):** Targets 52 kDa or 60 kDa proteins. It is the most common antibody in Sjogren Syndrome (70-90%) but is also found in Systemic Lupus Erythematosus (SLE) [1]. * **SS-B (La):** Targets a 48 kDa protein. It is highly specific for Sjogren Syndrome when found in conjunction with SS-A [1]. **Analysis of Incorrect Options:** * **A. DNA topoisomerase 1:** This is the target for **Anti-Scl-70** antibodies, which are highly specific for **Diffuse Cutaneous Systemic Sclerosis**. * **B. Histones:** Anti-histone antibodies are the hallmark of **Drug-Induced Lupus Erythematosus (DILE)**. * **D. Native DNA:** Also known as double-stranded DNA (dsDNA), these are the target for **Anti-dsDNA** antibodies, which are highly specific for **SLE** and correlate with renal involvement (lupus nephritis). **High-Yield Clinical Pearls for NEET-PG:** * **Neonatal Lupus:** Maternal SS-A (Ro) and SS-B (La) antibodies can cross the placenta, leading to neonatal lupus, characterized by **congenital heart block** and photosensitive rash. * **Diagnosis:** Sjogren syndrome is characterized by the triad of xerophthalmia (dry eyes), xerostomia (dry mouth), and parotid gland swelling [1]. * **Schirmer’s Test:** Used to quantify decreased lacrimal gland secretion (<5mm in 5 mins is positive). * **Malignancy Risk:** Patients with Sjogren Syndrome have a 40-fold increased risk of developing **B-cell MALT Lymphoma**.

Question 130: Which of the following statements regarding an acute attack of gouty arthritis is EXCEPT?

A. Joint aspirate reveals positively birefringent crystals.
B. Allopurinol should be started immediately. (Correct Answer)
C. Colchicine is known to provide relief.
D. Serum uric acid levels may be absolutely normal.

Explanation: ### Explanation **1. Why Option B is the Correct Answer (The "Except" Statement):** In an acute attack of gout, **Allopurinol should NOT be started immediately.** Allopurinol is a Xanthine Oxidase Inhibitor used for urate-lowering therapy (ULT). Starting it during an acute flare can cause a rapid shift in serum uric acid levels, leading to the mobilization of urate crystals from tissue stores into the joint space [1]. This paradoxically worsens or prolongs the acute inflammation. ULT should generally be initiated 2–4 weeks after the acute attack has completely resolved. (Note: If a patient is already on Allopurinol, it should be continued at the same dose). **2. Analysis of Other Options:** * **Option A:** This is incorrect for Gout. Gouty arthritis is characterized by **negatively birefringent**, needle-shaped Monosodium Urate (MSU) crystals [3]. Positively birefringent, rhomboid crystals are seen in Pseudogout (CPPD) [3]. * **Option C:** Colchicine is a first-line treatment for acute gout [1]. It works by inhibiting microtubule polymerization and leukocyte chemotaxis, thereby reducing inflammation. * **Option D:** Serum uric acid levels can be **normal or even low** during an acute attack because uric acid precipitates into the joints, or due to the uricosuric effect of inflammatory cytokines. A normal level does not rule out gout. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Polarized light microscopy of synovial fluid showing needle-shaped, negatively birefringent crystals (Yellow when parallel to the slow axis). * **First-line for Acute Gout:** NSAIDs (e.g., Indomethacin), Colchicine, or Corticosteroids. * **Target Urate Level:** In chronic management, the goal is to keep serum uric acid **< 6 mg/dL**. * **Radiology:** "Punched-out" erosions with overhanging edges (Martel’s sign) are seen in chronic tophaceous gout [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

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