Rheumatology and Immunology — MCQs
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A 45-year-old female, known case of Irritable Bowel Syndrome, presented with poorly localized pain, especially involving the axial skeleton. The pain was severe, associated with tenderness, and had been occurring for the past 4 months. She also reported fatigue, stiffness, sleep disturbance, cognitive dysfunction, anxiety, and depression. Lab and radiographic studies were normal. Which of the following drugs is NOT approved for the management of this patient's condition?
Scleroderma is characterized by which of the following?
Gottron sign is seen in which of the following conditions?
Which condition is specifically associated with anti-ds DNA antibodies?
A 34-year-old woman presents with a red rash over her cheeks, frequent oral ulcers, and pain and swelling in both wrists and small joints of her hands. Laboratory investigations reveal a positive ANA and 3+ proteinuria. Which of the following organ involvement will cause the most symptoms during the course of this disease?
Anti-neutrophil cytoplasmic antibodies (ANCA) are seen in which of the following conditions?
Anti-nuclear antibodies are not found in which of the following conditions?
C-ANCA is associated with which of the following conditions?
Anti-phospholipid syndrome is characterized by all of the following EXCEPT:
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?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 161: A 45-year-old female, known case of Irritable Bowel Syndrome, presented with poorly localized pain, especially involving the axial skeleton. The pain was severe, associated with tenderness, and had been occurring for the past 4 months. She also reported fatigue, stiffness, sleep disturbance, cognitive dysfunction, anxiety, and depression. Lab and radiographic studies were normal. Which of the following drugs is NOT approved for the management of this patient's condition?
- A. Cyclobenzaprine
- B. Duloxetine
- C. Pregabalin
- D. Tetrabenazine (Correct Answer)
Explanation: **Diagnosis: Fibromyalgia** The clinical presentation of chronic widespread pain (>3 months), axial involvement, tenderness, fatigue, sleep disturbances ("unrefreshing sleep"), and cognitive dysfunction ("fibro-fog") in a middle-aged female with normal labs and imaging is classic for **Fibromyalgia** [1]. It is frequently associated with functional syndromes like Irritable Bowel Syndrome (IBS) and mood disorders [2]. **Explanation of Options:** * **Tetrabenazine (Correct Answer):** This is a VMAT2 inhibitor used primarily for the treatment of chorea (e.g., Huntington’s disease) and tardive dyskinesia. It has no role in the management of fibromyalgia and can actually worsen depression, which is a common comorbidity in these patients. * **Duloxetine:** An SNRI (Serotonin-Norepinephrine Reuptake Inhibitor) FDA-approved for fibromyalgia. It is particularly useful for patients with comorbid depression or anxiety. * **Pregabalin:** A gabapentinoid (alpha-2-delta ligand) that reduces the release of excitatory neurotransmitters. It is FDA-approved to improve pain and sleep quality in fibromyalgia. * **Cyclobenzaprine:** A muscle relaxant structurally related to TCAs. While not first-line, it is frequently used off-label (and recommended by various guidelines) to improve sleep and reduce muscle pain in these patients. **High-Yield Clinical Pearls for NEET-PG:** * **Pathophysiology:** Central sensitization (augmented pain processing) rather than peripheral inflammation [1]. * **Diagnosis:** Primarily clinical. The 2010/2016 ACR criteria use the **Widespread Pain Index (WPI)** and **Symptom Severity Scale (SSS)** instead of just "tender points." * **FDA-Approved Drugs:** Only three drugs are FDA-approved for Fibromyalgia: **Pregabalin, Duloxetine, and Milnacipran.** * **Non-Pharmacological Rx:** Aerobic exercise is the most effective non-drug intervention. * **Labs:** ESR, CRP, and Muscle enzymes (CPK) are characteristically **normal** [1].
Question 162: Scleroderma is characterized by which of the following?
- A. Tightening of oral mucosa and periodontal involvement
- B. Multiple palmar keratosis
- C. Raynaud's phenomenon
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Scleroderma (Systemic Sclerosis) is a multisystem autoimmune disorder characterized by excessive collagen deposition leading to fibrosis of the skin and internal organs, alongside significant microvascular injury [1]. **Why "All of the Above" is correct:** * **Raynaud’s Phenomenon (Option C):** This is the most common initial manifestation (seen in >95% of patients). It results from episodic vasospasm of digital arteries in response to cold or stress. In scleroderma, it is "secondary Raynaud’s," often leading to digital ulcers due to structural vascular damage [1]. * **Oral and Periodontal Involvement (Option A):** Fibrosis affects the perioral tissues, leading to **microstomia** (limited mouth opening) and a "purse-string" appearance of the mouth. Radiographically, a classic high-yield finding is the **uniform thickening of the periodontal ligament (PDL) space**, even in the absence of tooth mobility. * **Palmar Keratosis (Option B):** While less discussed than sclerodactyly, skin thickening (sclerosis) can manifest as hyperkeratosis and induration of the palms [1]. The skin becomes tight, shiny, and loses its normal creases. **Clinical Pearls for NEET-PG:** 1. **Antibody Associations:** * **Limited Scleroderma (CREST):** Anti-Centromere antibodies (highly specific). * **Diffuse Scleroderma:** Anti-Scl-70 (Anti-topoisomerase I) and Anti-RNA polymerase III (associated with Scleroderma Renal Crisis). 2. **Gastrointestinal:** The most common site involved is the **Esophagus** (lower 2/3rd dysmotility), leading to GERD and "Watermelon Stomach" (GAVE). 3. **Pulmonary:** Interstitial Lung Disease (ILD) is the leading cause of mortality in diffuse disease, while Pulmonary Arterial Hypertension (PAH) is more common in limited disease. 4. **Diagnosis:** Look for "Salt and Pepper" pigmentation and telangiectasias on clinical vignettes [1].
Question 163: Gottron sign is seen in which of the following conditions?
- A. Polymyositis
- B. Dermatomyositis (Correct Answer)
- C. Polymyositis and Sjogren's syndrome
- D. Polymyositis and SLE
Explanation: **Explanation:** **Gottron sign** is a pathognomonic cutaneous manifestation of **Dermatomyositis (DM)**. It is characterized by symmetric, erythematous to violaceous scales or macules overlying the dorsal aspect of the interphalangeal (IP) and metacarpophalangeal (MCP) joints [1]. This occurs due to underlying microvascular damage and inflammation specific to the pathophysiology of DM. **Why the other options are incorrect:** * **Polymyositis (PM):** While PM shares similar proximal muscle weakness with DM [2], it is strictly an inflammatory myopathy **without** the characteristic skin involvement. If a patient has the clinical features of PM plus Gottron sign, the diagnosis automatically shifts to Dermatomyositis [2]. * **Sjogren’s Syndrome:** This is primarily characterized by sicca symptoms (dry eyes/mouth). While it can overlap with other connective tissue diseases, Gottron sign is not a feature. * **Systemic Lupus Erythematosus (SLE):** SLE presents with a malar rash that typically **spares the nasolabial folds**. On the hands, SLE rashes usually occur **between the joints** (interarticular), whereas Gottron sign specifically occurs **over the joints**. **High-Yield Clinical Pearls for NEET-PG:** * **Gottron Papules:** Raised, lichenoid papules over the knuckles (more specific than the "sign") [1]. * **Heliotrope Rash:** Violaceous eruption on the upper eyelids with periorbital edema [1]. * **Shawl Sign/V-sign:** Erythema over the upper back/shoulders or anterior chest [1]. * **Mechanic’s Hands:** Hyperkeratotic, cracked skin on the lateral fingers (associated with **Anti-Jo-1** antibodies and Interstitial Lung Disease) [2]. * **Malignancy:** Dermatomyositis has a strong association with internal malignancies (e.g., ovarian, lung, gastric); age-appropriate cancer screening is mandatory upon diagnosis [1].
Question 164: Which condition is specifically associated with anti-ds DNA antibodies?
- A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
- B. Systemic sclerosis
- C. CREST syndrome
- D. Sjogren's syndrome
Explanation: **Explanation:** **Systemic Lupus Erythematosus (SLE)** is the correct answer because anti-double-stranded DNA (anti-dsDNA) antibodies are highly specific (approx. 95–97%) for this condition. While Antinuclear Antibody (ANA) is the best screening test due to its high sensitivity, anti-dsDNA is a **confirmatory marker** [1]. Clinically, anti-dsDNA levels correlate with **disease activity**, particularly the development and severity of **Lupus Nephritis**. **Analysis of Incorrect Options:** * **Systemic Sclerosis (Diffuse):** Characteristically associated with **anti-Scl-70 (anti-topoisomerase I)** antibodies. * **CREST Syndrome (Limited Scleroderma):** Strongly associated with **anti-centromere** antibodies. * **Sjogren’s Syndrome:** Characterized by **anti-Ro (SS-A)** and **anti-La (SS-B)** antibodies [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most Specific Antibody for SLE:** Anti-Smith (anti-Sm) antibody (does not fluctuate with disease activity) [1]. * **Most Sensitive Antibody for SLE:** ANA (best initial screening test) [1]. * **Drug-Induced Lupus:** Associated with **anti-histone** antibodies; anti-dsDNA is typically absent. * **Neonatal Lupus/Congenital Heart Block:** Associated with maternal **anti-Ro/SSA** antibodies. * **Monitoring:** Anti-dsDNA and **complement levels (C3, C4)** are the two primary laboratory markers used to monitor SLE flares and renal involvement [1].
Question 165: A 34-year-old woman presents with a red rash over her cheeks, frequent oral ulcers, and pain and swelling in both wrists and small joints of her hands. Laboratory investigations reveal a positive ANA and 3+ proteinuria. Which of the following organ involvement will cause the most symptoms during the course of this disease?
- A. Renal pathology
- B. Cardiopulmonary pathology
- C. Musculoskeletal pathology (Correct Answer)
- D. Thrombotic events
Explanation: ### Explanation The clinical presentation (malar rash, oral ulcers, inflammatory arthritis, and proteinuria) in a young female is diagnostic of **Systemic Lupus Erythematosus (SLE)**. [1] **1. Why Musculoskeletal pathology is correct:** While renal involvement is the most significant predictor of mortality and morbidity, **musculoskeletal involvement** is the **most common clinical manifestation** of SLE, affecting over 90% of patients. [2] It is typically the earliest symptom and causes the most frequent symptoms (pain, stiffness, and swelling) throughout the disease course. The arthritis in SLE is characteristically inflammatory, symmetrical, and non-erosive (unlike Rheumatoid Arthritis). [4] **2. Why other options are incorrect:** * **Renal pathology:** Although 3+ proteinuria indicates Lupus Nephritis (a major cause of morbidity), it is often asymptomatic in early stages. Only about 50% of patients develop clinically significant renal disease. * **Cardiopulmonary pathology:** While pleuritis and pericarditis are common, they occur less frequently than joint involvement. [3] * **Thrombotic events:** These are associated with secondary Antiphospholipid Syndrome (APS). While life-threatening, they occur in a minority of SLE patients (approx. 30% have APL antibodies, but fewer have clinical events). **Clinical Pearls for NEET-PG:** * **Most common symptom/initial presentation:** Arthritis/Arthralgia (>90%). * **Most common cardiac manifestation:** Pericarditis. * **Most common pulmonary manifestation:** Pleuritis. * **Jaccoud’s Arthropathy:** A reversible, non-erosive deformity seen in SLE due to ligamentous laxity. * **Best Screening Test:** ANA (High sensitivity). [3] * **Most Specific Test:** Anti-dsDNA and Anti-Smith (Anti-dsDNA levels also correlate with disease activity/nephritis). [3]
Question 166: Anti-neutrophil cytoplasmic antibodies (ANCA) are seen in which of the following conditions?
- A. Wegener's Granulomatosis (Correct Answer)
- B. Diabetes mellitus
- C. Rheumatoid arthritis
- D. Churg-Strauss syndrome
Explanation: **Anti-neutrophil cytoplasmic antibodies (ANCA)** are autoantibodies directed against antigens found in the cytoplasmic granules of neutrophils and monocytes. They serve as primary serological markers for **ANCA-associated vasculitides (AAV)**. **1. Why Option A is correct:** **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA) is the classic condition associated with ANCA. Specifically, it shows a **c-ANCA (cytoplasmic)** pattern in over 90% of active systemic cases, with antibodies directed against **Proteinase-3 (PR3)**. It typically presents with a triad of upper respiratory tract, lower respiratory tract, and renal involvement (pauci-immune glomerulonephritis). **2. Why other options are incorrect:** * **B. Diabetes mellitus:** This is a metabolic disorder characterized by hyperglycemia due to insulin deficiency or resistance; it has no primary autoimmune association with ANCA. * **C. Rheumatoid arthritis:** While an autoimmune condition, it is primarily associated with **Rheumatoid Factor (RF)** and **Anti-CCP** antibodies. While p-ANCA can occasionally be seen in RA, it is not a diagnostic or characteristic marker. * **D. Churg-Strauss syndrome:** (Note: While Churg-Strauss/EGPA *is* an ANCA-associated vasculitis, it is typically associated with **p-ANCA/Anti-MPO** in only ~40-50% of cases [1]. In the context of standard NEET-PG questions, Wegener’s is the "most" classic and definitive answer for ANCA association). **High-Yield Clinical Pearls for NEET-PG:** * **c-ANCA (PR3-ANCA):** Highly specific for **Granulomatosis with Polyangiitis (GPA)**. * **p-ANCA (MPO-ANCA):** Associated with **Microscopic Polyangiitis (MPA)**, **Eosinophilic Granulomatosis with Polyangiitis (EGPA/Churg-Strauss)**, and Primary Sclerosing Cholangitis (PSC) [1]. * **Pauci-immune:** This term refers to the lack of significant immune complex deposition on immunofluorescence in the glomerulonephritis associated with these conditions.
Question 167: Anti-nuclear antibodies are not found in which of the following conditions?
- A. Systemic Lupus Erythematosus (SLE)
- B. Sarcoidosis (Correct Answer)
- C. Diffuse Scleroderma
- D. Drug-induced lupus
Explanation: The presence of **Anti-nuclear antibodies (ANA)** is a hallmark of systemic autoimmune rheumatic diseases (SARDs). ANA serves as a screening tool for conditions where the immune system loses tolerance to self-antigens within the cell nucleus [4]. **Why Sarcoidosis is the Correct Answer:** Sarcoidosis is a multisystem inflammatory disease characterized by the formation of **non-caseating granulomas**. Its pathogenesis is primarily driven by a **Type IV (cell-mediated) hypersensitivity** reaction involving T-lymphocytes and macrophages [2], rather than a B-cell mediated autoantibody response. Therefore, ANA is typically negative in Sarcoidosis. **Analysis of Incorrect Options:** * **Systemic Lupus Erythematosus (SLE):** ANA is the best initial screening test for SLE, with a sensitivity of **>95-99%** [1]. A negative ANA virtually rules out SLE (high negative predictive value). * **Drug-induced Lupus (DILE):** ANA is positive in nearly 100% of cases. The classic marker is **Anti-histone antibodies** (found in >90% of DILE cases). * **Diffuse Scleroderma (Systemic Sclerosis):** ANA is positive in approximately 95% of patients [1]. Specific markers include **Anti-Scl-70 (anti-topoisomerase I)** for diffuse disease and **Anti-centromere** for limited disease (CREST syndrome). **High-Yield Clinical Pearls for NEET-PG:** 1. **ANA Pattern:** A "Homogeneous" pattern is common in SLE, while a "Nucleolar" pattern is highly suggestive of Systemic Sclerosis. 2. **Most Specific Test for SLE:** Anti-dsDNA and Anti-Smith (Anti-Sm) antibodies [1]. 3. **Sarcoidosis Markers:** Elevated **Serum ACE levels**, hypercalciuria/hypercalcemia, and bilateral hilar lymphadenopathy on CXR (Stage I) [3]. 4. **ANA-Negative SLE:** Extremely rare; historically associated with Anti-Ro (SS-A) antibodies [1].
Question 168: C-ANCA is associated with which of the following conditions?
- A. Wegener's granulomatosis (Correct Answer)
- B. Microscopic polyangitis
- C. Churg Strauss syndrome
- D. Polyarteritis nodosa (PAN)
Explanation: 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**.
Question 169: Anti-phospholipid syndrome is characterized by all of the following EXCEPT:
- A. Association with SLE
- B. Thrombocytopenia and rash
- C. Thrombotic disorders
- D. Pancytopenia (Correct Answer)
Explanation: 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.
Question 170: 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?
- A. P-ANCA
- B. C-ANCA
- C. Anti-HCV antibody (Correct Answer)
- D. Anti-HAV antibody
Explanation: ### Explanation The clinical triad of **cutaneous vasculitis** (typically palpable purpura [1]), **glomerulonephritis**, and **synovitis** (arthralgia/arthritis) is the classic presentation of **Mixed Cryoglobulinemia (Type II and III)**. **1. Why Anti-HCV antibody is the correct answer:** Mixed cryoglobulinemia is a small-vessel vasculitis caused by the deposition of immune complexes. There is a very strong association between **Hepatitis C Virus (HCV)** infection and Mixed Cryoglobulinemia; approximately 80–90% of patients with mixed cryoglobulinemia are HCV-positive. Therefore, screening for Anti-HCV antibodies is a crucial diagnostic step in a patient presenting with these multisystemic vasculitic features. **2. Why the other options are incorrect:** * **C-ANCA (PR3-ANCA):** Highly specific for **Granulomatosis with Polyangiitis (GPA)**. While GPA involves the kidneys and skin, it characteristically involves the upper and lower respiratory tracts (sinusitis, lung nodules), which are absent here. * **P-ANCA (MPO-ANCA):** Associated with **Microscopic Polyangiitis (MPA)** and Eosinophilic Granulomatosis with Polyangiitis (EGPA) [1]. While MPA causes glomerulonephritis and vasculitis, the epidemiological link to HCV makes cryoglobulinemia a more likely primary consideration for this specific triad. * **Anti-HAV antibody:** Hepatitis A is an acute, self-limiting infection and is not associated with chronic immune-complex mediated vasculitis or cryoglobulinemia. **3. Clinical Pearls for NEET-PG:** * **Meltzer’s Triad:** Purpura, arthralgia, and asthenia (weakness) are the classic signs of cryoglobulinemia. * **Complement levels:** In Mixed Cryoglobulinemia, **C4 levels are characteristically very low**, while C3 may be normal or mildly decreased. * **Rheumatoid Factor (RF):** Cryoglobulins in Type II/III often have RF activity; thus, a positive RF in a vasculitis patient should raise suspicion for HCV-related cryoglobulinemia. * **Treatment:** Addressing the underlying HCV infection with direct-acting antivirals (DAAs) is the definitive management.
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
Practice Questions
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