Rheumatology and Immunology Practice Questions

Q: C-ANCA is associated with which of the following conditions?

Wegener's granulomatosis. Explanation: **C-ANCA (Cytoplasmic Antineutrophil Cytoplasmic Antibody)** is highly specific for **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA). The target antigen for C-ANCA is **Proteinase-3 (PR3)**. In GPA, the classic clinical triad involves the upper respiratory tract (sinusitis, saddle nose deformity), lower respiratory tract (hemoptysis, cavitary nodules), and kidneys (pauci-immune glomerulonephritis). **Analysis of Options:** * **Microscopic Polyangiitis (MPA):** This is primarily associated with **P-ANCA** (Perinuclear-ANCA), which targets the enzyme **Myeloperoxidase (MPO)**. Unlike GPA, MPA lacks granulomatous inflammation. * **Churg-Strauss Syndrome (EGPA):** This condition is also associated with **P-ANCA** (MPO-ANCA) in about 40-50% of cases [1]. It is characterized by asthma, peripheral eosinophilia, and extravascular granulomas [1]. * **Polyarteritis Nodosa (PAN):** PAN is a medium-vessel vasculitis that is characteristically **ANCA-negative**. It is strongly associated with Hepatitis B infection and involves microaneurysms (seen on angiography). **High-Yield Clinical Pearls for NEET-PG:** 1. **C-ANCA = PR3-ANCA** (Wegener’s/GPA). 2. **P-ANCA = MPO-ANCA** (Microscopic Polyangiitis, Churg-Strauss, Primary Sclerosing Cholangitis, and Ulcerative Colitis) [1]. 3. **Wegener’s Triad:** Sinus + Lung + Kidney. 4. **Drug-induced Lupus** is associated with anti-histone antibodies, while **Drug-induced ANCA vasculitis** (e.g., by Hydralazine or Propylthiouracil) is usually P-ANCA positive. 5. **Negative ANCA** in a systemic vasculitis should immediately make you think of **PAN** or **Kawasaki disease**.

Q: Anti-phospholipid syndrome is characterized by all of the following EXCEPT:

Pancytopenia. Explanation: Anti-phospholipid Syndrome (APS) is an autoimmune prothrombotic state characterized by the presence of antiphospholipid antibodies (aPL) in the setting of venous/arterial thrombosis or pregnancy complications. **Why Pancytopenia is the Correct Answer:** APS is primarily a **thrombotic and obstetric** disorder. While it frequently involves the hematologic system, it typically manifests as **isolated thrombocytopenia** [2] (due to platelet consumption or anti-platelet antibodies) and occasionally autoimmune hemolytic anemia. It does **not** cause bone marrow suppression or leukopenia; therefore, **pancytopenia** is not a characteristic feature of APS. **Analysis of Other Options:** * **Association with SLE:** APS can be primary or secondary. Secondary APS is most commonly associated with **Systemic Lupus Erythematosus (SLE)** [2], occurring in approximately 30-40% of SLE patients. * **Thrombocytopenia and Rash:** Thrombocytopenia is a classic laboratory finding in APS. The characteristic rash associated with APS is **Livedo Reticularis** [1] (a mottled, purplish, net-like pattern), which results from small vessel occlusion [1]. * **Thrombotic Disorders:** This is the hallmark of the disease. APS causes both **venous thrombosis** (most commonly DVT) and **arterial thrombosis** (most commonly Stroke/TIA). **High-Yield Clinical Pearls for NEET-PG:** 1. **Diagnostic Criteria (Sapporo):** Requires at least one clinical criteria (Thrombosis or Pregnancy loss) AND one laboratory criteria (Lupus anticoagulant, Anti-cardiolipin, or Anti-β2-glycoprotein 1 antibodies). 2. **Paradoxical Finding:** APS causes a **prolonged aPTT** *in vitro* (due to interference with phospholipids in the assay), but causes **thrombosis** *in vivo*. 3. **False Positive VDRL:** Patients with APS often have a false-positive syphilis test (VDRL/RPR) because the reagin antibodies cross-react with the cardiolipin used in the test.

Q: All of the following are features of Systemic Lupus Erythematosus (SLE) except?

Idiopathic pulmonary nodules. **Explanation:** The correct answer is **D. Idiopathic pulmonary nodules**. While SLE can involve the lungs, pulmonary nodules are not a characteristic feature [2]. Instead, they are a classic extra-articular manifestation of **Rheumatoid Arthritis (Caplan’s Syndrome)**. SLE-related pulmonary involvements typically include pleuritis (most common), interstitial lung disease, or the rare but life-threatening "Shrinking Lung Syndrome" [2]. **Analysis of Options:** * **A. Sterile vegetations on valve cusps:** This refers to **Libman-Sacks Endocarditis**. These are small, sterile, non-bacterial vegetations found on both sides of the valve leaflets (mitral valve most common). * **B. Raynaud's phenomenon:** This occurs in approximately 30% of SLE patients [1]. It is characterized by reversible digital ischemia in response to cold or stress. * **C. Atherosclerosis:** SLE is an independent risk factor for accelerated atherosclerosis. Chronic inflammation, corticosteroid use, and the presence of anti-phospholipid antibodies contribute to a significantly higher risk of myocardial infarction in these patients [2]. **Clinical Pearls for NEET-PG:** * **Most common cardiac manifestation:** Pericarditis. * **Most common pulmonary manifestation:** Pleuritis/Pleural effusion (Exudative) [2]. * **Specific Autoantibodies:** Anti-dsDNA (correlates with disease activity and lupus nephritis) and Anti-Smith (most specific) [3]. * **Drug-Induced Lupus:** Associated with Anti-Histone antibodies; usually spares the CNS and Kidneys. * **Libman-Sacks Endocarditis:** Unlike infective endocarditis, these vegetations are sterile and can occur on the undersurface of valves.

Q: Fibromyalgia is characterized by:

Reduced delta sleep wave activity. Fibromyalgia is a chronic central pain sensitization syndrome characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances [1]. **1. Why Option A is Correct:** The hallmark of sleep disturbance in fibromyalgia is the **intrusion of alpha waves (wakefulness) into delta waves (deep sleep)**, often referred to as "alpha-delta sleep." Delta waves are characteristic of Stage 3 and 4 NREM sleep, which is the restorative phase. Reduced delta wave activity leads to non-restorative sleep, which is a key diagnostic feature and contributes to the pathogenesis of chronic fatigue and lowered pain thresholds [1]. **2. Why Other Options are Incorrect:** * **Option B:** Fibromyalgia is a **chronic condition** [3]. It does not resolve spontaneously and typically requires long-term multidisciplinary management. * **Option C:** By definition, fibromyalgia involves **widespread tenderness** [1]. While the 1990 ACR criteria focused on 11/18 specific "tender points," the 2010/2016 revised criteria emphasize a Widespread Pain Index (WPI) and Symptom Severity (SS) scale [2]. * **Option D:** While physical activity is recommended, **low-impact aerobic exercise** (like walking or swimming) is the gold standard [3]. Intensive or traditional physiotherapy can sometimes exacerbate pain if not tailored specifically to the patient’s tolerance. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females (20–50 years). * **Pathophysiology:** Central sensitization and "wind-up" phenomenon; decreased levels of serotonin and norepinephrine in descending inhibitory pathways [1]. * **Diagnosis:** It is a **diagnosis of exclusion**. Labs (ESR, CRP, Muscle enzymes) are characteristically **normal** [2]. * **Management:** First-line pharmacological treatments include **Amitriptyline** (TCA), **Duloxetine** (SNRI), or **Pregabalin** (Anticonvulsant). Opioids and Steroids are generally **ineffective**.

Q: A 26-year-old woman develops a red rash over her cheeks and pain, and swelling in both wrists as well as several small joints in her hands. The rash gets worse on sun exposure and involves her cheeks, nose, ears, and chin. Medical evaluation reveals oral ulceration and 3+ proteinuria. Which of the following is the most specific test for the diagnosis of this condition?

Anti-Sm antibody. ### Explanation **Diagnosis:** The clinical presentation of malar rash (photosensitive), symmetrical polyarthritis (wrists and small joints), oral ulcers, and significant proteinuria (3+) in a young female is classic for **Systemic Lupus Erythematosus (SLE)** [1]. #### 1. Why Anti-Sm antibody is the correct answer: While many antibodies are associated with SLE, **Anti-Smith (Anti-Sm) antibodies** are highly specific (nearly 99%) for the diagnosis [1]. Although they are only present in about 20-30% of patients, their presence is virtually pathognomonic for SLE [1]. Along with Anti-dsDNA, it is a part of the ACR/SLICC classification criteria. #### 2. Why the other options are incorrect: * **Lupus erythematosus (LE) cells:** This is an obsolete test where neutrophils ingest denatured nuclear material. It lacks both sensitivity and specificity compared to modern assays and is no longer used in clinical practice. * **Antinuclear antibody (ANA):** This is the **best initial screening test** because it is positive in >95% of SLE patients (high sensitivity) [1]. However, it is **not specific**, as it can be positive in other autoimmune diseases, infections, and even healthy individuals [1]. * **Anti-Ro (SS-A) antibody:** While associated with SLE, it is more classically linked to **Sj'ogren’s syndrome**, Neonatal Lupus (congenital heart block), and Subacute Cutaneous Lupus (SCLE) [1]. #### Clinical Pearls for NEET-PG: * **Most Sensitive Test:** ANA (Best for screening) [1]. * **Most Specific Tests:** Anti-Sm and Anti-dsDNA [1]. * **Best for Monitoring Disease Activity:** Anti-dsDNA levels (correlates with lupus nephritis and low C3/C4 levels) [1]. * **Drug-Induced Lupus:** Anti-Histone antibodies are the hallmark (Procainamide, Hydralazine). * **Antiphospholipid Syndrome (APS):** Look for Anti-cardiolipin, Anti-̢2 glycoprotein I, or Lupus anticoagulant.

Question 1

C-ANCA is associated with which of the following conditions?

Accepted Answer

Wegener's granulomatosis

Answer

Microscopic polyangitis

Answer

Churg Strauss syndrome

Answer

Polyarteritis nodosa (PAN)

Question 2

Anti-phospholipid syndrome is characterized by all of the following EXCEPT:

Accepted Answer

Pancytopenia

Answer

Association with SLE

Answer

Thrombocytopenia and rash

Answer

Thrombotic disorders

Question 3

A 50-year-old male presents with symptoms of cutaneous vasculitis, glomerulonephritis, and synovitis. Which of the following investigations will be helpful in the diagnosis?

Accepted Answer

Anti-HCV antibody

Answer

P-ANCA

Answer

C-ANCA

Answer

Anti-HAV antibody

Question 4

A 45-year-old hypertensive female patient presented with recurrent sinusitis, otitis media, nasal blockage, cough, haemoptysis, and chest discomfort. On examination, she had nasal septal perforation, palpable purpura, and non-healing ulcers in lower limbs. Laboratory findings included anemia, leukocytosis, raised ESR, proteinuria, and increased C-ANCA levels. Histopathological examination revealed necrotizing vasculitis and granuloma formation. What is the first-line drug for the above condition?

Accepted Answer

Cyclophosphamide

Answer

Corticosteroids

Answer

5-Fluorouracil

Answer

Azathioprine

Question 5

A 45-year-old lady presents with features suggestive of mononeuritis multiplex. She has a history of regular attacks of bronchial asthma preceded by allergic rhinitis. She also has cutaneous purpura. Blood routine examination reveals eosinophilia. What is the most likely diagnosis to be considered in this clinical scenario?

Accepted Answer

Churg-Strauss syndrome

Answer

Microscopic polyangiitis

Answer

Endogenous bronchial asthma

Answer

Wegener's vasculitis

Question 6

All of the following are features of Systemic Lupus Erythematosus (SLE) except?

Accepted Answer

Idiopathic pulmonary nodules

Answer

Sterile vegetations on valve cusps

Answer

Raynaud's phenomenon

Answer

Atherosclerosis

Question 7

Humoral immunodeficiency is suspected in a patient and is under investigation. Which of the following infections would not be consistent with the diagnosis?

Accepted Answer

Pneumocystis jirovecii pneumonia

Answer

Giardiasis

Answer

Recurrent sinusitis

Answer

Recurrent subcutaneous abscesses

Question 8

Fibromyalgia is characterized by:

Accepted Answer

Reduced delta sleep wave activity

Answer

Rapid spontaneous resolution

Answer

Musculoskeletal pain without local tenderness

Answer

Physiotherapy is useful

Question 9

A 45-year-old woman presents with pain in her fingers upon exposure to cold, arthralgias, and difficulty swallowing solid food. What is the most useful test for a definitive diagnosis?

Accepted Answer

Anti-Scl-70 antibody

Answer

Rheumatoid factor

Answer

ANA

Answer

Anti-Jo-1 antibody

Question 10

A 26-year-old woman develops a red rash over her cheeks and pain, and swelling in both wrists as well as several small joints in her hands. The rash gets worse on sun exposure and involves her cheeks, nose, ears, and chin. Medical evaluation reveals oral ulceration and 3+ proteinuria. Which of the following is the most specific test for the diagnosis of this condition?

Accepted Answer

Anti-Sm antibody

Answer

Lupus erythematosus (LE) cells

Answer

Antinuclear antibody (ANA)

Answer

Anti-Ro antibody

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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