Rheumatology and Immunology — MCQs

A 45-year-old woman presents with a 4-month history of severe headaches and pain and blanching of the hands upon exposure to cold. She is a nonsmoker. Over the past 6 months, she has noticed progressive difficulty in swallowing solid food. Physical examination reveals smooth and tight skin over the face and fingers. The serologic test for anti-Scl-70 (anti topoisomerase) is positive. Painful hands in this patient are best described using which of the following terms?

Q134Easy

Which of the following is NOT a feature of sarcoidosis?

Q135Easy

Elevated ESR is seen in the following conditions except?

Q136Medium

In which of the following conditions is rheumatoid factor not present in serum?

Q137Easy

Hepatitis C virus is associated with which of the following conditions?

Q138Medium

A 35-year-old woman consults a physician because of increasing discomfort in her hands over the past year. Her symptoms have developed insidiously and are often worst for the first hour after rising. She has also been experiencing vague symptoms of fatigue and malaise, particularly in the early afternoon. Physical examination of her hands is notable for tenderness and synovial thickening of most of the small hand joints of both hands, particularly the proximal interphalangeal and metacarpophalangeal joints. A number of joints elsewhere, including in the feet, elbows, and ankles, are also symmetrically involved. An autoantibody directed against IgG is detected in serum. Which of the following is the most likely diagnosis?

Q139Medium

A 30-year-old male presents with sudden onset pain, swelling, and redness of the left first metatarsophalangeal joint. A needle aspirate of the joint shows needle-shaped, negatively birefringent crystals. The physician prescribed a drug for the patient, but he developed nausea, vomiting, and diarrhea on the next day after taking the medication. Which of the following is the most likely drug that was prescribed to this patient?

Q140Medium

Which of the following is a type of seronegative spondyloarthropathy?

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 131: The Schober test is used to assess which of the following conditions?

A. Rheumatoid Arthritis
B. Ankylosing Spondylitis (Correct Answer)
C. Reiter's Syndrome
D. Enteropathic Arthritis

Explanation: The **Schober test** (and its modified version) is a clinical examination tool used to quantify the **range of motion of the lumbar spine**, specifically lumbar flexion. **Why Ankylosing Spondylitis (AS) is correct:** AS is a chronic inflammatory disease characterized by sacroiliitis and progressive fusion of the axial skeleton (syndesmophytes). [1] As the disease progresses, the spine becomes rigid (the "bamboo spine" appearance on X-ray), leading to a significant loss of lumbar mobility. [3] The Schober test objectively measures this restriction. * **Procedure:** A mark is made at the level of the posterior superior iliac spines (L5), and another 10 cm above it. Upon maximal forward flexion, an increase of **less than 5 cm** (total distance <15 cm) indicates restricted lumbar mobility, a hallmark of AS. **Why other options are incorrect:** * **Rheumatoid Arthritis (RA):** RA primarily affects small peripheral joints (PIP, MCP) and the cervical spine (atlanto-axial subluxation). It typically spares the lumbosacral spine. * **Reiter’s Syndrome (Reactive Arthritis) & Enteropathic Arthritis:** While these are part of the Seronegative Spondyloarthropathy group and can involve the spine, the Schober test is the classic diagnostic physical exam finding specifically emphasized for the chronic, progressive spinal involvement seen in **Ankylosing Spondylitis**. [2] **High-Yield Clinical Pearls for NEET-PG:** * **Modified Schober Test:** Uses three marks (one at L5, one 5 cm below, and one 10 cm above). An increase of **<6 cm** is considered abnormal. * **HLA-B27:** Strongly associated with AS (>90% of cases). [2] * **Extra-articular manifestation:** The most common is **Acute Anterior Uveitis**. [2] * **Radiology:** Look for "dagger sign," "shiny corner sign" (Romanus lesions), and "bamboo spine." [3]

Question 132: What is the Silk Road disease?

A. Behcet's syndrome (Correct Answer)
B. Giant cell arteritis
C. Henoch-Schonlein purpura
D. Wegener's granulomatosis

Explanation: **Behcet’s syndrome** is classically referred to as the **"Silk Road disease"** because it follows the ancient trading route extending from the Mediterranean basin through the Middle East to East Asia (specifically Turkey, Iran, China, and Japan). It is a systemic variable-vessel vasculitis characterized by a strong genetic association with the **HLA-B51** allele. ### Why the other options are incorrect: * **Giant cell arteritis (B):** This is a large-vessel vasculitis primarily affecting the elderly (age >50). It is most common in individuals of Northern European descent, not along the Silk Road. * **Henoch-Schonlein purpura (C):** Now known as IgA Vasculitis, this is a small-vessel vasculitis common in children, characterized by the tetrad of palpable purpura, arthritis, abdominal pain, and renal involvement. It has no specific geographic link to the Silk Road. * **Wegener's granulomatosis (D):** Now known as Granulomatosis with Polyangiitis (GPA), this is a necrotizing granulomatous small-vessel vasculitis associated with c-ANCA (PR3-ANCA). ### High-Yield Clinical Pearls for NEET-PG: * **Clinical Triad:** Recurrent oral ulcers (most common), genital ulcers (most specific), and uveitis. * **Pathergy Test:** A unique diagnostic feature where a sterile skin papule or pustule forms 24–48 hours after a needle prick. * **Vessel Involvement:** It is unique because it involves **both arteries and veins** of all sizes (variable-vessel vasculitis). * **Major Cause of Morbidity:** Posterior uveitis leading to blindness and CNS involvement (Neuro-Behcet’s).

Question 133: A 45-year-old woman presents with a 4-month history of severe headaches and pain and blanching of the hands upon exposure to cold. She is a nonsmoker. Over the past 6 months, she has noticed progressive difficulty in swallowing solid food. Physical examination reveals smooth and tight skin over the face and fingers. The serologic test for anti-Scl-70 (anti topoisomerase) is positive. Painful hands in this patient are best described using which of the following terms?

A. Chilblains
B. Homans' sign
C. Intermittent claudication
D. Raynaud phenomenon (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Raynaud phenomenon** The patient presents with a classic triad suggestive of **Systemic Sclerosis (Scleroderma)**: sclerodactyly (tight skin), esophageal dysmotility (difficulty swallowing), and **Raynaud phenomenon** (RP). RP is characterized by episodic digital ischemia triggered by cold or stress, manifesting as a triphasic color change: **White** (pallor due to vasoconstriction), **Blue** (cyanosis due to deoxygenation), and **Red** (rubor due to reperfusion). In this case, the presence of **anti-Scl-70 antibodies** confirms the diagnosis of Diffuse Cutaneous Systemic Sclerosis, where RP is often the initial presenting symptom. In these patients, symmetrical thickening, tightening, and induration of the skin (sclerodactyly) is a hallmark feature resulting from abnormal fibroblast activation [1]. **Analysis of Incorrect Options:** * **A. Chilblains (Pernio):** These are painful, itchy, inflammatory skin lesions (red/purple bumps) caused by chronic exposure to cold, non-freezing damp air. They do not typically involve the classic blanching or the systemic features seen here. * **B. Homans' sign:** This refers to calf pain on dorsiflexion of the foot, traditionally used as a clinical sign for Deep Vein Thrombosis (DVT). It is neither sensitive nor specific. * **C. Intermittent claudication:** This is muscle pain (usually in the calves) that occurs during exercise and is relieved by rest, caused by Peripheral Artery Disease (atherosclerosis). It does not present with cold-induced blanching of the fingers. **Clinical Pearls for NEET-PG:** * **Primary RP (Raynaud Disease):** Occurs in isolation, usually in young women, with no underlying tissue injury. * **Secondary RP (Raynaud Syndrome):** Associated with connective tissue diseases (most commonly Scleroderma). It is often more severe and can lead to digital ulcers or gangrene. * **Antibody Correlation:** * **Anti-Scl-70 (Anti-topoisomerase I):** Specific for Diffuse Systemic Sclerosis (high risk of interstitial lung disease) [1]. * **Anti-Centromere:** Specific for Limited Systemic Sclerosis (CREST syndrome). * **First-line treatment:** Calcium Channel Blockers (e.g., Nifedipine).

Question 134: Which of the following is NOT a feature of sarcoidosis?

A. Interstitial Lung Disease
B. Erythema Nodosum
C. Retinal degeneration (Correct Answer)
D. Arthritis

Explanation: Sarcoidosis is a multisystem, chronic granulomatous disease characterized by the formation of **non-caseating granulomas**. **Why "Retinal Degeneration" is the correct answer:** While sarcoidosis frequently involves the eyes (occurring in about 25% of cases), it typically presents as **uveitis** (most commonly anterior, but can be posterior or pan-uveitis), conjunctival follicles, or lacrimal gland enlargement [1]. It does **not** cause retinal degeneration. If the retina is involved, it usually manifests as retinal vasculitis or "candle-wax drippings" (periphlebitis), but not primary degeneration of the retinal layers. **Analysis of Incorrect Options:** * **A. Interstitial Lung Disease (ILD):** The lungs are the most common organ involved (>90%). Sarcoidosis is a classic cause of restrictive lung disease and bilateral hilar lymphadenopathy, which can progress to pulmonary fibrosis (Stage IV) [1]. * **B. Erythema Nodosum:** This is a hallmark cutaneous manifestation, often seen in the acute form of the disease (**Löfgren syndrome**) [1]. It presents as tender, erythematous nodules on the shins. * **C. Arthritis:** Joint involvement is common. Acute sarcoidosis often presents with migratory polyarthritis (especially involving the ankles), while chronic sarcoidosis can cause persistent dactylitis ("sausage digits") [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** Triad of Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis (Good prognosis) [1]. * **Heerfordt Syndrome (Uveoparotid fever):** Uveitis, Parotid swelling, Facial nerve palsy, and Fever. * **Diagnosis:** Elevated **Serum ACE levels** (non-specific) and biopsy showing non-caseating granulomas. * **Asteroid bodies** and **Schaumann bodies** are characteristic microscopic findings within the granulomas.

Question 135: Elevated ESR is seen in the following conditions except?

A. Polymyositis rheumatica
B. Multiple myeloma
C. Temporal arteritis
D. Polycythemia rubra (Correct Answer)

Explanation: **Explanation:** The **Erythrocyte Sedimentation Rate (ESR)** is a non-specific marker of inflammation [1]. It measures the rate at which red blood cells (RBCs) sink to the bottom of a tube. This process is primarily governed by the balance between pro-sedimentation factors (like fibrinogen and globulins) and the negative surface charge of RBCs (zeta potential) that keeps them apart. **Why Polycythemia Rubra is the correct answer:** In **Polycythemia rubra vera**, there is an absolute increase in the number of RBCs [3]. This high concentration of cells increases the internal friction and viscosity of the blood, which physically hinders the settling process. Consequently, the ESR is characteristically **low or near zero** [2]. **Analysis of incorrect options:** * **Polymyalgia Rheumatica (PMR) & Temporal Arteritis:** These are systemic inflammatory vasculitides. They are classic "high ESR" conditions, often presenting with an ESR >50 mm/hr (and frequently >100 mm/hr) [2]. A high ESR is a key diagnostic criterion for both. * **Multiple Myeloma:** This plasma cell dyscrasia leads to high levels of monoclonal immunoglobulins (paraproteins) [2]. These positively charged proteins neutralize the negative charge on RBCs, promoting **Rouleaux formation**, which causes the cells to sediment rapidly, leading to a markedly elevated ESR. **High-Yield Clinical Pearls for NEET-PG:** 1. **Low ESR Causes:** Polycythemia, Sickle cell anemia (abnormal shape prevents stacking), Afibrinogenemia, Spherocytosis, and extreme Leukocytosis. 2. **Markedly Elevated ESR (>100 mm/hr):** Think of Multiple Myeloma, Temporal Arteritis, Polymyalgia Rheumatica, Metastatic Malignancy, and Chronic Infections (e.g., Tuberculosis) [2]. 3. **ESR vs. CRP:** CRP is an acute-phase reactant that rises and falls faster than ESR, making it better for monitoring acute changes [4]. ESR is more influenced by age, gender, and red cell morphology.

Question 136: In which of the following conditions is rheumatoid factor not present in serum?

A. Rheumatoid arthritis
B. Felty's syndrome
C. Still's disease (Correct Answer)
D. Present in all of the above

Explanation: **Explanation:** The correct answer is **Still’s disease**. Rheumatoid Factor (RF) is an autoantibody (usually IgM) directed against the Fc portion of IgG [1]. While its presence is a hallmark of several connective tissue diseases, its absence is a defining feature of certain conditions. **1. Why Still’s Disease is the correct answer:** Adult-Onset Still’s Disease (AOSD) is a systemic autoinflammatory disorder characterized by the classic triad of high spiking fever, evanescent salmon-pink rash, and arthritis. By definition, **Still’s disease is "seronegative,"** meaning both Rheumatoid Factor (RF) and Anti-CCP antibodies are characteristically **absent**. Diagnosis relies on clinical criteria (Yamaguchi criteria) and markedly elevated serum ferritin levels. **2. Why the other options are incorrect:** * **Rheumatoid Arthritis (RA):** Approximately 70–80% of patients with RA are "seropositive" for RF [2]. While not pathognomonic, it is a key diagnostic marker included in the ACR/EULAR classification criteria. * **Felty’s Syndrome:** This is a severe manifestation of long-standing RA characterized by the triad of **RA, splenomegaly, and neutropenia** [3]. Patients with Felty’s syndrome are almost universally (nearly 100%) positive for high titers of RF [3]. **Clinical Pearls for NEET-PG:** * **RF is NOT specific for RA:** It is found in Sjogren’s syndrome (75-95%), SLE, and chronic infections like Subacute Bacterial Endocarditis (SBE), Hepatitis C, and Tuberculosis. * **Still’s Disease Marker:** Look for **Hyperferritinemia** (often >1000 ng/mL) and **leukocytosis** in the clinical vignette. * **Prognosis:** High titers of RF in RA patients usually correlate with more aggressive joint destruction and extra-articular manifestations.

Question 137: Hepatitis C virus is associated with which of the following conditions?

A. Churg- Strauss syndrome
B. Hypersensitivity Vasculitis
C. Cryoglobulinemic Vasculitis (Correct Answer)
D. Polyarteritis nodosa

Explanation: **Explanation:** **Cryoglobulinemic Vasculitis** is the correct answer because of its strong, well-established association with **Hepatitis C Virus (HCV)**. Approximately 80-90% of patients with Mixed Cryoglobulinemia (Type II and III) are infected with HCV. The virus triggers a chronic immune response leading to the formation of immune complexes (cryoglobulins) that precipitate in cold temperatures, causing small-vessel vasculitis. Clinical features typically include the "Meltzer’s triad": palpable purpura, arthralgia, and weakness. **Analysis of Incorrect Options:** * **Churg-Strauss Syndrome (EGPA):** This is a small-vessel vasculitis characterized by asthma, eosinophilia, and granulomatous inflammation [1]. It is not associated with HCV. * **Hypersensitivity Vasculitis:** Also known as Leukocytoclastic vasculitis, this is usually triggered by drugs (e.g., penicillin, sulfa drugs) or acute infections, rather than chronic viral hepatitis. * **Polyarteritis Nodosa (PAN):** While PAN is a systemic vasculitis associated with viral hepatitis, its classic association is with **Hepatitis B Virus (HBV)**, not HCV. PAN affects medium-sized vessels and characteristically spares the lungs. **NEET-PG High-Yield Pearls:** * **HCV + Vasculitis** = Cryoglobulinemic Vasculitis (Small vessel). * **HBV + Vasculitis** = Polyarteritis Nodosa (Medium vessel). * **Complement levels:** In Cryoglobulinemic vasculitis, **C4** is characteristically very low, while C3 may be normal or slightly low. * **Treatment:** The primary treatment for HCV-associated cryoglobulinemia is antiviral therapy (DAAs) to eliminate the underlying viral trigger.

Question 138: A 35-year-old woman consults a physician because of increasing discomfort in her hands over the past year. Her symptoms have developed insidiously and are often worst for the first hour after rising. She has also been experiencing vague symptoms of fatigue and malaise, particularly in the early afternoon. Physical examination of her hands is notable for tenderness and synovial thickening of most of the small hand joints of both hands, particularly the proximal interphalangeal and metacarpophalangeal joints. A number of joints elsewhere, including in the feet, elbows, and ankles, are also symmetrically involved. An autoantibody directed against IgG is detected in serum. Which of the following is the most likely diagnosis?

A. Osteoarthritis
B. Osteomyelitis
C. Osteoporosis
D. Rheumatoid arthritis (Correct Answer)

Explanation: ### Explanation **1. Why Rheumatoid Arthritis (RA) is Correct:** The clinical presentation is classic for RA. The key diagnostic features include: * **Symmetric Polyarthritis:** Involvement of small joints of the hands (MCP and PIP joints) and feet bilaterally [1]. * **Morning Stiffness:** Lasting more than one hour is a hallmark of inflammatory arthritis [1]. * **Constitutional Symptoms:** Fatigue and malaise suggest a systemic inflammatory process [1]. * **Serology:** The "autoantibody directed against IgG" refers to **Rheumatoid Factor (RF)**, which is an IgM antibody against the Fc portion of IgG [1]. **2. Why Incorrect Options are Wrong:** * **A. Osteoarthritis (OA):** This is a degenerative disease. Stiffness usually lasts <30 minutes, it typically involves the Distal Interphalangeal (DIP) joints (Heberden’s nodes), and it lacks systemic symptoms or RF positivity [1]. * **B. Osteomyelitis:** This is an acute or chronic bone infection. It presents with localized pain, fever, and swelling, usually involving a single site (monoarticular) rather than symmetric polyarthritis. * **C. Osteoporosis:** This is a "silent" metabolic bone disease characterized by decreased bone mineral density. It does not cause joint inflammation, synovial thickening, or morning stiffness unless a fracture occurs. **3. NEET-PG High-Yield Pearls:** * **Joint Sparing:** RA characteristically **spares the DIP joints** (unlike OA and Psoriatic Arthritis) [1]. * **Specific Marker:** While RF is sensitive, **Anti-CCP (Anti-cyclic citrullinated peptide)** antibodies are the most specific marker for RA and predict joint destruction [1]. * **Radiology:** Early signs include periarticular osteopenia and marginal erosions. * **Deformities:** Late-stage findings include Swan-neck deformity, Boutonniere deformity, and ulnar deviation of the MCP joints.

Question 139: A 30-year-old male presents with sudden onset pain, swelling, and redness of the left first metatarsophalangeal joint. A needle aspirate of the joint shows needle-shaped, negatively birefringent crystals. The physician prescribed a drug for the patient, but he developed nausea, vomiting, and diarrhea on the next day after taking the medication. Which of the following is the most likely drug that was prescribed to this patient?

A. Allopurinol
B. Colchicine (Correct Answer)
C. Steroids
D. Indomethacin

Explanation: The clinical presentation of sudden onset pain, swelling, and redness in the first metatarsophalangeal (MTP) joint (Podagra), combined with the presence of **needle-shaped, negatively birefringent crystals**, confirms a diagnosis of **Acute Gouty Arthritis** [1]. **1. Why Colchicine is correct:** Colchicine is a first-line agent for acute gout. It works by binding to tubulin, inhibiting microtubule polymerization, and interfering with neutrophil chemotaxis and degranulation. The most characteristic and dose-limiting side effects of colchicine are **gastrointestinal (GI) disturbances**, specifically **nausea, vomiting, and diarrhea**. These symptoms occur in up to 80% of patients at high doses and serve as a clinical marker of toxicity. **2. Why the other options are incorrect:** * **Allopurinol (A):** This is a Xanthine Oxidase inhibitor used for chronic urate-lowering therapy [2]. It should **never** be started during an acute attack as it can precipitate or worsen the flare by causing rapid shifts in serum urate levels [2]. * **Steroids (C):** While used in acute gout (especially if NSAIDs/Colchicine are contraindicated), they typically do not cause immediate profuse diarrhea. * **Indomethacin (D):** This is a potent NSAID often used for gout. While it can cause GI upset or peptic ulcers, the classic "diarrhea" side effect immediately following administration is much more characteristic of Colchicine. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Polarized light microscopy showing negatively birefringent (yellow when parallel to the axis) needle-shaped crystals (Monosodium Urate). * **Colchicine Toxicity:** Can lead to bone marrow suppression, neuropathy, and myopathy (especially when used with statins). * **Management Strategy:** Treat the acute attack first (NSAIDs, Colchicine, or Steroids); wait 2 weeks after the flare subsides before initiating Allopurinol [2].

Question 140: Which of the following is a type of seronegative spondyloarthropathy?

A. Rheumatoid arthritis
B. Gouty arthritis
C. CPPD
D. Reiter's disease (Correct Answer)

Explanation: Explanation: Seronegative spondyloarthropathies (SpA) are a group of inflammatory joint diseases characterized by the absence of Rheumatoid Factor (RF) and a strong association with the **HLA-B27** gene [1]. **Why Reiter’s Disease is Correct:** Reiter’s disease, now more commonly known as **Reactive Arthritis**, is a classic member of the seronegative SpA group [1]. It typically presents as an asymmetric oligoarthritis following a gastrointestinal (e.g., *Salmonella*) or urogenital (e.g., *Chlamydia*) infection [1], [2]. It is defined by the clinical triad: **Urethritis, Conjunctivitis, and Arthritis** ("Can't see, can't pee, can't climb a tree") [2]. **Why the other options are incorrect:** * **A. Rheumatoid Arthritis:** This is a seropositive inflammatory arthritis (usually positive for RF and Anti-CCP). It typically involves small joints symmetrically and lacks the axial involvement and HLA-B27 association seen in SpA [5]. * **B. Gouty Arthritis:** This is a crystal-induced arthropathy caused by the deposition of monosodium urate crystals. It is a metabolic, not an autoimmune spondyloarthropathy. * **C. CPPD (Pseudogout):** Calcium Pyrophosphate Deposition Disease is another crystal-induced arthropathy characterized by rhomboid-shaped crystals and chondrocalcinosis on X-ray. **NEET-PG High-Yield Pearls:** * **Mnemonic for Seronegative SpA (PEAR):** **P**soriatic arthritis, **E**nteropathic arthritis (IBD-associated), **A**nkylosing spondylitis, **R**eactive arthritis [1], [4]. * **Common Features:** Asymmetric peripheral arthritis, **Enthesitis** (inflammation at tendon insertion sites—most common site is the Achilles tendon), Sacroiliitis, and Uveitis [1], [2], [3]. * **Dermatological finding in Reiter’s:** Keratoderma blennorrhagicum (vesicular, crusty lesions on palms/soles) [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

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Osteoarthritis

Practice Questions

Primary Immunodeficiency Disorders

Practice Questions

Autoinflammatory Syndromes

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Sjögren's Syndrome

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Antiphospholipid Syndrome

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