Rheumatology and Immunology Practice Questions

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

Arthralgia. ### Explanation Acute Rheumatic Fever (ARF) is diagnosed using the **Revised Jones Criteria**. This criteria categorizes clinical and laboratory findings into **Major** and **Minor** manifestations [1]. **Why Arthralgia is the correct answer:** Arthralgia (joint pain without objective findings of inflammation) is classified as a **Minor manifestation**. In the diagnosis of ARF, a patient must meet either two major criteria OR one major and two minor criteria (plus evidence of a preceding Group A Streptococcal infection) [1]. Since the question asks for the option that is NOT a major manifestation, arthralgia is the correct choice. **Analysis of Incorrect Options (Major Criteria):** The mnemonic **J♥NES** is commonly used to remember the five Major manifestations: * **J (Joints):** **Polyarthritis** (Option B) is a major criterion. It is typically migratory, affecting large joints (knees, ankles, elbows, wrists). * **♥ (Carditis):** **Carditis** (Option A) is the most serious major criterion, often presenting as valvulitis (mitral regurgitation is most common) [1]. * **N (Nodules):** **Subcutaneous nodules** (Option C) are firm, painless, small bumps usually found over bony prominences or tendons. * **E (Erythema Marginatum):** A pink, non-pruritic, evanescent rash with serpiginous borders. * **S (Sydenham Chorea):** Involuntary, purposeless movements; often a late manifestation [1]. **NEET-PG High-Yield Pearls:** * **Most common manifestation:** Migratory Polyarthritis. * **Most serious manifestation:** Carditis (can lead to chronic Rheumatic Heart Disease) [1]. * **Minor Criteria:** Arthralgia, Fever, Elevated ESR/CRP, and Prolonged PR interval on ECG. * **Important Note:** If polyarthritis is counted as a major criterion, arthralgia cannot be counted as an additional minor criterion in the same patient.

Q: A young woman who has suffered recurrent abortions presents with thrombosis of leg veins. What is the most likely diagnosis?

Antiphospholipid antibody syndrome. **Explanation:** The clinical presentation of **recurrent pregnancy loss (RPL)** combined with a **venous thromboembolic event** (leg vein thrombosis) is a classic hallmark of **Antiphospholipid Antibody Syndrome (APS)**. **1. Why Antiphospholipid Antibody Syndrome (APS) is correct:** APS is an autoimmune hypercoagulable state characterized by the presence of antiphospholipid antibodies (Lupus anticoagulant, Anti-cardiolipin, or Anti-β2 glycoprotein I). These antibodies induce a prothrombotic state by activating endothelial cells and platelets. In pregnancy, this leads to placental infarction and thrombosis of spiral arteries, resulting in recurrent abortions (typically after 10 weeks), while systemic involvement leads to venous or arterial thrombosis. **2. Why the other options are incorrect:** * **Chromosomal abnormality:** While this is the most common cause of *sporadic* first-trimester abortions, it does not cause maternal vascular thrombosis. * **Factor VIII deficiency:** This is Hemophilia A, a bleeding disorder. It would lead to excessive bleeding, not thrombosis. * **Increased antithrombin III levels:** Antithrombin III is a natural anticoagulant. *Increased* levels would decrease clotting risk; it is the *deficiency* of Antithrombin III that causes thrombosis. **Clinical Pearls for NEET-PG:** * **Sapporo Criteria:** Diagnosis requires at least one clinical criterion (vascular thrombosis or specific pregnancy morbidity) AND one laboratory criterion (positive APLA tests 12 weeks apart). * **Pregnancy Morbidity in APS:** ≥3 unexplained consecutive spontaneous abortions before 10th week; OR ≥1 premature birth (<34 weeks) due to eclampsia/preeclampsia/placental insufficiency; OR ≥1 unexplained fetal death ≥10th week. * **Management:** For pregnant women with APS and prior thrombosis, the standard treatment is **Low Molecular Weight Heparin (LMWH) plus Low-Dose Aspirin (LDA).**

Q: Pseudogout more commonly involves which joint?

Knee. **Explanation:** **Pseudogout**, clinically known as **Calcium Pyrophosphate Deposition (CPPD)** disease, is a crystal-induced arthropathy caused by the deposition of calcium pyrophosphate dihydrate crystals in the articular cartilage (chondrocalcinosis) and synovial fluid [1]. 1. **Why the Knee is Correct:** The **knee** is the most frequently affected joint in pseudogout, involved in over 50% of acute attacks [1]. Unlike gout, which favors small distal joints, CPPD has a predilection for large joints. The fibrocartilage and hyaline cartilage of the knee are primary sites for crystal nucleation [3]. 2. **Why Other Options are Incorrect:** * **MTP joint of great toe:** This is the classic site for **Gout** (Podagra), caused by monosodium urate crystals [2]. While pseudogout can occur here, it is much less common. * **Shoulder and Hip:** While CPPD can affect these joints (especially in the elderly or in "Crowned Dens Syndrome" of the cervical spine), they are involved significantly less often than the knee and wrist. **High-Yield Clinical Pearls for NEET-PG:** * **Synovial Fluid Analysis:** The gold standard for diagnosis is identifying **rhomboid-shaped**, **weakly positively birefringent** crystals under polarized light microscopy. * **Radiology:** Look for **chondrocalcinosis** (linear calcification of articular cartilage or menisci) [1]. * **Associated Metabolic Conditions:** Always screen for "The 4 Hs": **H**yperparathyroidism, **H**emochromatosis, **H**ypomagnesemia, and **H**ypophosphatasia [1]. * **Treatment:** Acute management involves NSAIDs, colchicine, or intra-articular glucocorticoids.

Q: Which of the following is true about Felty's syndrome?

Associated with high titers of rheumatoid factor. Felty’s syndrome (FS) is a rare but severe extra-articular manifestation of long-standing Rheumatoid Arthritis (RA). It is classically defined by the clinical triad of **Rheumatoid Arthritis, Splenomegaly, and Neutropenia.** [1] **Why Option D is correct:** Patients with Felty’s syndrome almost universally exhibit **high titers of Rheumatoid Factor (RF)** and Anti-cyclic citrullinated peptide (anti-CCP) antibodies. [1] The condition is strongly associated with the **HLA-DR4** serotype. These high titers reflect the intense underlying systemic inflammation and the presence of immune complexes that contribute to the pathogenesis of the syndrome. **Analysis of Incorrect Options:** * **Option A:** Felty’s syndrome is more common in **females** (matching the general gender distribution of RA), typically occurring in the 5th to 7th decades of life. [1] * **Option B:** It occurs in the **late/chronic phase** of RA, usually after 10–15 years of aggressive, erosive joint disease. [1] * **Option C:** While it includes RA and splenomegaly, the hematological hallmark is **neutropenia** (Absolute Neutrophil Count <2000/mm³), not lymphopenia. [1] **Clinical Pearls for NEET-PG:** * **Infections:** The primary clinical concern is recurrent bacterial infections (skin and respiratory) due to severe neutropenia. * **Large Granular Lymphocyte (LGL) Leukemia:** There is a significant phenotypic overlap between FS and T-cell LGL leukemia; both may present with the same triad. * **Extra-articular features:** Patients often present with systemic features like vasculitis, leg ulcers, and lymphadenopathy. [1] * **Treatment:** Management focuses on controlling the underlying RA, typically using Methotrexate. Granulocyte colony-stimulating factor (G-CSF) may be used for refractory neutropenia.

Q: Which antinuclear antibody is specific for Systemic Lupus Erythematosus (SLE)?

Anti-dsDNA. ### Explanation **Correct Answer: A. Anti-dsDNA** **1. Why Anti-dsDNA is the Correct Answer:** In Systemic Lupus Erythematosus (SLE), **Anti-dsDNA** and **Anti-Smith (Anti-Sm)** antibodies [1] are considered highly specific (nearly 100%). While Anti-dsDNA is specific for the diagnosis, it is also clinically significant because its titers fluctuate with disease activity [2], particularly in **Lupus Nephritis**. **2. Analysis of Incorrect Options:** * **B. Anti-nuclear antibodies (ANA):** This is the **best screening test** for SLE due to its high sensitivity (>95%) [1]. However, it lacks specificity as it can be positive in other autoimmune diseases (Scleroderma, Sjögren’s), chronic infections, or even in healthy individuals [1]. * **C. Anti-centromere antibody:** This is highly specific for **Limited Cutaneous Systemic Sclerosis** (formerly CREST syndrome), not SLE. * **D. Anti-histone antibody:** This is the hallmark of **Drug-Induced Lupus (DILE)**. While it can be present in idiopathic SLE, its presence in the absence of other SLE-specific markers strongly suggests a drug-induced etiology (e.g., Hydralazine, Procainamide, Isoniazid). **3. NEET-PG High-Yield Pearls:** * **Most Sensitive Test for SLE:** ANA (Indirect Immunofluorescence is the gold standard). * **Most Specific Test for SLE:** Anti-Smith (Anti-Sm) followed by Anti-dsDNA [1]. * **Antibody correlating with Disease Activity/Renal involvement:** Anti-dsDNA [2]. * **Antibody associated with Neonatal Lupus/Congenital Heart Block:** Anti-Ro (SS-A) [1]. * **Antibody associated with Psychosis/CNS Lupus:** Anti-ribosomal P protein. * **Drug-Induced Lupus:** Characterized by Anti-histone antibodies; usually spares the kidney and CNS.

Q: A 50-year old female presents with sudden blindness. There is scalp tenderness and pain while combing her hair. Temporal artery biopsy shows intimal thickening with granulomatous inflammation. What is the diagnosis?

Giant cell arteritis. ### Explanation **Correct Option: A. Giant cell arteritis (GCA)** The clinical triad of **sudden blindness** (due to anterior ischemic optic neuropathy), **scalp tenderness** (pain while combing hair), and **jaw claudication** in an elderly patient is classic for Giant Cell Arteritis (Temporal Arteritis). The histopathological hallmark is **granulomatous inflammation** [1] of the media with **intimal thickening** and fragmentation of the internal elastic lamina. It primarily affects large and medium-sized arteries, particularly the branches of the external carotid artery. **Why other options are incorrect:** * **B. Takayasu Arteritis:** While also a large-vessel vasculitis [2] with granulomatous inflammation, it typically affects females **under 40 years** ("young female arteritis") and involves the aorta and its primary branches, leading to absent pulses (pulseless disease). * **C. Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis associated with Hepatitis B. It causes necrotizing inflammation (not granulomatous) and typically presents with renal failure, hypertension, and abdominal pain, sparing the lungs. * **D. Microscopic Polyangiitis (MPA):** A small-vessel vasculitis associated with p-ANCA. It presents with necrotizing glomerulonephritis and pulmonary capillaritis, lacking the granulomatous features seen in GCA. **NEET-PG High-Yield Pearls:** * **Association:** Strongly associated with **Polymyalgia Rheumatica (PMR)** (proximal muscle pain/stiffness) [1]. * **Diagnosis:** Elevated **ESR** (often >100 mm/hr) is a highly sensitive screening tool [1]. * **Biopsy:** Temporal artery biopsy is the gold standard [1], but "skip lesions" can occur; hence, a long segment (2-3 cm) should be sampled. * **Management:** Do not wait for biopsy results. Start **high-dose corticosteroids** immediately to prevent permanent blindness in the contralateral eye [1].

Q: Syndesmophytes are seen in which of the following conditions?

Ankylosing Spondylitis. **Explanation:** **Syndesmophytes** are the hallmark radiological feature of **Ankylosing Spondylitis (AS)**. They represent vertical bony outgrowths that develop due to inflammation and subsequent ossification of the outer fibers of the **annulus fibrosus** of the intervertebral discs. * **Why Option A is correct:** In AS, chronic enthesitis (inflammation at the site where ligaments/tendons attach to bone) leads to the formation of these thin, vertical, and symmetrical bony bridges between adjacent vertebrae. When these bridges connect multiple levels, it creates the classic **"Bamboo Spine"** appearance on X-ray. * **Why Option B is incorrect:** Rheumatoid Arthritis (RA) primarily affects the synovial joints (like the atlantoaxial joint in the spine) and causes bone **erosions** and joint space narrowing, not new bone formation like syndesmophytes. * **Why Option C is incorrect:** Osteoarthritis (OA) of the spine (Spondylosis) produces **Osteophytes**. Unlike syndesmophytes, osteophytes are horizontal, thick, and claw-like protrusions that arise from the vertebral body margins due to mechanical stress, rather than vertical ossification of the ligaments. **High-Yield Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated with Ankylosing Spondylitis (>90% of cases). * **Sacroiliitis:** The earliest radiological sign of AS (usually bilateral and symmetrical). * **Dagger Sign:** A single central radiodense line on X-ray due to ossification of the supraspinous and interspinous ligaments. * **Schober’s Test:** Used clinically to assess the restriction of lumbar spine flexion. * **Marginal vs. Non-marginal:** AS has *marginal* syndesmophytes, while Psoriatic Arthritis and Reiter’s syndrome have *non-marginal* (bulky/asymmetric) syndesmophytes.

Question 1

A female presents with symmetrical small joint polyarthritis for 2 weeks. Labs show rheumatoid factor levels at 1:320 (positive is 1:40) and anti-CCP at 58 units (40 to 59 units are considered strongly positive). An antinuclear antibody test is negative. Labs also reveal positive cytomegalovirus and parvovirus IgG, and negative parvovirus IgM. The ESR is 62 mm/hour. What is the appropriate next step in the management of this patient?

Accepted Answer

Methotrexate 12.5 mg a week with liver function tests in 1 month

Answer

Naproxen 500 mg twice a day and follow up in 1 month

Answer

Anti-histone antibodies, anti-DS-DNA, and complement levels

Answer

Prednisone 60 mg a day and follow up in 2 weeks

Question 2

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

Accepted Answer

Arthralgia

Answer

Carditis

Answer

Polyarthritis

Answer

Subcutaneous nodules

Question 3

A young woman who has suffered recurrent abortions presents with thrombosis of leg veins. What is the most likely diagnosis?

Accepted Answer

Antiphospholipid antibody syndrome

Answer

Chromosomal abnormality

Answer

Factor VIII deficiency

Answer

Increased antithrombin III levels

Question 4

Pseudogout more commonly involves which joint?

Accepted Answer

Knee

Answer

Shoulder

Answer

Hip

Answer

MTP joint of great toe

Question 5

Which of the following is true about Felty's syndrome?

Accepted Answer

Associated with high titers of rheumatoid factor

Answer

More common in males

Answer

Occurs in the early phase of rheumatoid arthritis

Answer

Characterized by rheumatoid arthritis, lymphopenia, and splenomegaly

Question 6

Which antinuclear antibody is specific for Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Anti-dsDNA

Answer

Anti-nuclear antibodies

Answer

Anti-centromere antibody

Answer

Anti-histone antibody

Question 7

A 50-year old female presents with sudden blindness. There is scalp tenderness and pain while combing her hair. Temporal artery biopsy shows intimal thickening with granulomatous inflammation. What is the diagnosis?

Accepted Answer

Giant cell arteritis

Answer

Takayasu arteritis

Answer

Polyarteritis nodosa

Answer

Microscopic polyangiitis

Question 8

A 34-year-old female presents with hypertension, pinched facies, and progressive dysphagia with a decreased tone of the lower esophageal sphincter. What is the clinical diagnosis?

Accepted Answer

Scleroderma

Answer

Hiatus hernia

Answer

Rolling hernia

Answer

Diffuse esophageal spasm

Question 9

Which is a common antibody found in Polymyositis and Dermatomyositis?

Accepted Answer

Anti-aminoacyl-tRNA synthetase

Answer

SS-7

Answer

SS-8

Answer

Anti hystidyl transfer synthetase

Question 10

Syndesmophytes are seen in which of the following conditions?

Accepted Answer

Ankylosing Spondylitis

Answer

Rheumatoid Arthritis

Answer

Osteoarthritis

Answer

All of the above

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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