Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT true regarding Felty's syndrome?

Neutrophilia. **Explanation:** Felty’s syndrome is a rare but severe extra-articular manifestation of long-standing Rheumatoid Arthritis (RA). It is classically defined by a **triad** of: 1. **Rheumatoid Arthritis** (usually seropositive and erosive) 2. **Splenomegaly** [1] 3. **Neutropenia** (Absolute Neutrophil Count < 2000/mm³) **Why Option B is correct:** The hallmark of Felty’s syndrome is **Neutropenia**, not neutrophilia. The low neutrophil count results from a combination of splenic sequestration and immune-mediated destruction of neutrophils. This leads to an increased risk of recurrent bacterial infections, particularly of the skin and respiratory tract. **Why other options are incorrect:** * **A. Splenomegaly:** This is a core component of the diagnostic triad. While the degree of enlargement varies, it is present in almost all cases. [1] * **C. Female preponderance:** Like most autoimmune conditions and RA itself, Felty’s syndrome is significantly more common in females (approx. 3:1 ratio), typically occurring in the 5th to 7th decades of life. [1] * **D. Associated with RA:** By definition, Felty’s syndrome occurs in patients with chronic, established Rheumatoid Arthritis. [1] **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly associated with **HLA-DR4**. * **Serology:** Patients are almost always positive for high titers of **Rheumatoid Factor (RF)** and often anti-CCP. [1] * **Large Granular Lymphocyte (LGL) Leukemia:** There is a significant clinical overlap between Felty’s syndrome and T-cell LGL leukemia; both present with neutropenia and splenomegaly. * **Treatment:** The primary treatment is methotrexate (to control the underlying RA), which often improves the neutrophil count. Granulocyte colony-stimulating factor (G-CSF) can be used in severe refractory infections.

Q: According to the 1987 modified ARA criteria, which joint is NOT involved in Rheumatoid arthritis?

Tarsometatarsal. **Explanation:** Rheumatoid Arthritis (RA) is a chronic inflammatory polyarthritis that characteristically involves **small joints of the hands and feet**, typically in a symmetrical fashion. According to the **1987 ARA (American Rheumatism Association) criteria**, joint involvement is a hallmark, but the disease has a strong predilection for specific joints while characteristically sparing others. **Why Tarsometatarsal is the correct answer:** RA typically involves the **Metatarsophalangeal (MTP)** joints and the **Proximal Interphalangeal (PIP)** joints. However, it characteristically **spares** the Distal Interphalangeal (DIP) joints and the **Tarsometatarsal (TMT)** joints [1]. Involvement of the TMT joints and the DIP joints is more suggestive of Osteoarthritis (OA) or Psoriatic Arthritis [1]. **Analysis of Incorrect Options:** * **Knee (A):** The knee is one of the most common large joints involved in RA [2], often leading to Baker’s cysts. * **Ankle (B):** While less common than the small joints of the hand, the ankle is frequently involved in established RA. * **Metatarsophalangeal (D):** MTP joint involvement is a classic feature of RA. In many patients, "squeezing the forefoot" (Gaenslen's maneuver) elicits pain due to early MTP inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Joints Spared in RA:** DIP joints, Tarsometatarsal joints, and the Thoracolumbar spine (RA only affects the **Cervical spine**, specifically the C1-C2 joint). * **1987 vs. 2010 Criteria:** The 1987 criteria focused on chronicity (6 weeks duration), while the 2010 ACR/EULAR criteria focus on early diagnosis and include ACPA (Anti-CCP) titers [2]. * **Most Specific Marker:** Anti-CCP (ACPA) is more specific for RA than Rheumatoid Factor (RF). * **First Joint Involved:** Often the MCP or PIP joints.

Q: Which of the following is NOT a characteristic associated with Lupus anticoagulant?

Prolonged prothrombin time (PT). Lupus anticoagulant (LA) is a misnomer; it is an **antiphospholipid antibody** that paradoxically causes a prothrombotic state *in vivo* while causing a prolonged clotting time *in vitro*. **Why Option D is the correct answer:** Lupus anticoagulant primarily interferes with phospholipid-dependent coagulation tests. It characteristically causes a **prolonged Activated Partial Thromboplastin Time (aPTT)** [1], not Prothrombin Time (PT). This occurs because the antibodies bind to the phospholipids used in the lab assay, interfering with the assembly of the tenase and prothrombinase complexes. Crucially, this prolongation **does not correct** with a 1:1 mixing study (indicating an inhibitor is present, rather than a factor deficiency) [1]. **Why other options are incorrect:** * **A & B (Abortions and Arterial Thrombosis):** These are hallmark clinical features of Antiphospholipid Syndrome (APS). LA increases the risk of both venous and arterial thrombosis, as well as pregnancy complications like recurrent miscarriages (usually >10 weeks) and pre-eclampsia. * **C (Rashes):** APS is frequently associated with **Livedo reticularis** (a mottled, purplish lace-like rash) and is commonly seen in patients with Systemic Lupus Erythematosus (SLE) [2]. **High-Yield Clinical Pearls for NEET-PG:** * **The Paradox:** LA causes **clots in the body** (thrombosis) but **prolonged bleeding time in the test tube** (aPTT). * **Diagnosis:** Requires the **DRVVT (Dilute Russell Viper Venom Test)**, which is more specific for LA than aPTT. * **Criteria:** To diagnose APS, you need one clinical criteria (thrombosis or pregnancy loss) and one lab criteria (LA, Anti-cardiolipin, or Anti-β2 glycoprotein I antibodies) positive on two occasions 12 weeks apart.

Q: Hepatitis B is associated with which of the following conditions?

Polyarteritis nodosa. **Explanation:** **Polyarteritis Nodosa (PAN)** is a systemic necrotizing vasculitis that typically affects medium-sized muscular arteries. The association between **Hepatitis B Virus (HBV)** and PAN is a classic medical correlation. In these cases, the pathogenesis involves the deposition of immune complexes containing Hepatitis B surface antigen (HBsAg) within the vessel walls, leading to inflammation and "fibrinoid necrosis." Approximately 10–30% of PAN cases are associated with HBV [1]. **Analysis of Options:** * **Polyarteritis Nodosa (Correct):** Characterized by "beading" on angiography (microaneurysms) and involvement of renal and visceral arteries, while characteristically **sparing the lungs**. * **Wegener’s Granulomatosis (GPA):** This is a small-vessel vasculitis strongly associated with **c-ANCA (PR3-ANCA)**, not viral hepatitis. It primarily involves the upper/lower respiratory tract and kidneys. * **Systemic Lupus Erythematosus (SLE):** An autoimmune disease characterized by ANA and anti-dsDNA antibodies [2]. While viral infections can trigger flares, there is no specific primary association with HBV. * **Sjogren Syndrome:** An autoimmune destruction of exocrine glands (sicca symptoms) [2]. It is more frequently associated with **Hepatitis C**, not Hepatitis B. **NEET-PG High-Yield Pearls:** 1. **PAN & HBV:** Always screen a patient with PAN for Hepatitis B [1]. 2. **Angiography:** The "gold standard" for PAN diagnosis showing multiple microaneurysms (rosary sign). 3. **ANCA Status:** PAN is typically **ANCA-negative**, distinguishing it from Microscopic Polyangiitis (MPA). 4. **Hepatitis C Associations:** Strongly linked to **Mixed Cryoglobulinemia** and Porphyria Cutanea Tarda.

Q: HLA B27 is seen associated with which of the following conditions?

Ankylosing spondylitis. **Explanation:** **Ankylosing Spondylitis (AS)** is the correct answer because it is the prototype of **Seronegative Spondyloarthropathies (SpA)**. These conditions are characterized by the absence of Rheumatoid Factor (RF) and a strong genetic association with the **HLA-B27** allele [1]. In patients with AS, the association is remarkably high, with over **90%** of patients testing positive for HLA-B27 [1]. The molecule plays a role in disease pathogenesis through molecular mimicry or the "misfolding protein" hypothesis, leading to sacroiliitis and enthesitis. **Analysis of Incorrect Options:** * **Rheumatoid Arthritis (RA):** This is primarily associated with **HLA-DR4** (specifically the "shared epitope"). RA is characterized by symmetric small joint involvement and the presence of RF or Anti-CCP antibodies. * **Sjogren Syndrome:** This autoimmune exocrinopathy is most commonly associated with **HLA-DR3** and **HLA-DQ2**, along with antibodies like Anti-Ro (SS-A) and Anti-La (SS-B). * **Scleroderma (Systemic Sclerosis):** While genetic factors exist, it is more strongly linked to **HLA-DR1, DR3, and DR5**, and characterized by specific autoantibodies like Anti-Scl-70 (diffuse) and Anti-centromere (limited). **Clinical Pearls for NEET-PG:** * **Mnemonic for HLA-B27 (PAIR):** **P**soriatic arthritis, **A**nkylosing spondylitis, **I**nflammatory bowel disease-associated arthritis, and **R**eactive arthritis [1]. * **Highest Association:** While AS has a 90% association, HLA-B27 is also found in 8% of the healthy general population; thus, it is **not** a diagnostic test but a supportive one [2]. * **Radiology High-Yield:** Look for "Bamboo Spine" (syndesmophytes) and "Dagger Sign" on X-rays [2].

Q: A 29-year-old male with a history of a long leisure trip presented with right knee pain and a swollen joint. What is the most likely diagnosis?

Reiter's disease. ### Explanation **Correct Option: C. Reiter's Disease (Reactive Arthritis)** The clinical presentation of a young male with acute monoarthritis (swollen right knee) following a "long leisure trip" is a classic vignette for **Reactive Arthritis**. In the context of NEET-PG, a "long trip" often implies exposure to new sexual partners (leading to *Chlamydia trachomatis* urethritis) or unsanitary food (leading to enteric infections like *Salmonella* or *Campylobacter*). Reactive Arthritis typically presents as an asymmetric oligoarthritis, predominantly affecting the lower limbs, 1–4 weeks after a urogenital or gastrointestinal infection [1]. **Why other options are incorrect:** * **A. Sarcoidosis:** While it can cause acute arthritis (Lofgren’s syndrome), it usually presents with bilateral hilar lymphadenopathy, erythema nodosum, and symmetric ankle involvement rather than isolated knee pain following travel. * **B. Tuberculosis:** TB arthritis is usually a chronic, slowly progressive monoarthritis (Poncet’s disease is rare). It does not typically follow the acute "post-travel" pattern seen in reactive cases. * **D. Behcet’s Disease:** This is characterized by the triad of oral ulcers, genital ulcers, and uveitis. While it causes arthritis, the lack of mucosal lesions makes it less likely than Reiter's in this scenario. **Clinical Pearls for NEET-PG:** * **The Classic Triad:** "Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)" [1]. * **HLA Association:** Strongly associated with **HLA-B27** (seen in 60–80% of cases) [2]. * **Cutaneous Markers:** Look for **Keratoderma blennorrhagicum** (brownish plaques on palms/soles) and **Circinate balanitis** [1]. * **Joint Fluid:** Sterile on culture (hence "reactive"), but high inflammatory markers.

Q: Erythema marginatum is seen in which of the following conditions?

Rheumatic fever. Explanation: **Erythema marginatum** is a classic cutaneous manifestation and one of the **Major Jones Criteria** used for the diagnosis of **Acute Rheumatic Fever (ARF)**. It is a non-pruritic, pink or faint red, evanescent rash with a pale center and a serpiginous (snake-like) or ring-like border [1]. It typically appears on the trunk and proximal extremities, sparing the face, and is often accentuated by heat (e.g., a warm bath). **Why the other options are incorrect:** * **Typhoid/Enteric Fever (Options B & C):** These are characterized by **"Rose spots,"** which are small (2-4 mm), blanching, salmon-colored maculopapules typically found on the chest and abdomen during the second week of illness. * **Drug Reactions (Option A):** These most commonly present as **Erythema multiforme** (target lesions), morbilliform eruptions, or urticaria [2]. While some drugs can cause annular rashes, Erythema marginatum is specifically pathognomonic for ARF in the context of the Jones Criteria. **High-Yield Clinical Pearls for NEET-PG:** * **Jones Criteria Mnemonic (Major):** **J**oint (Polyarthritis), **O** (Carditis - shaped like a heart), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham chorea [1]. * **Erythema Marginatum vs. Erythema Chronicum Migrans:** Do not confuse the two. Erythema chronicum migrans is the "bull's eye" rash associated with **Lyme disease**. * **Erythema Nodosum:** This is a painful, red, nodular eruption on the shins, seen in Sarcoidosis, TB, and IBD, but it is *not* a major criterion for ARF.

Question 1

Which of the following is NOT true regarding Felty's syndrome?

Accepted Answer

Neutrophilia

Answer

Splenomegaly

Answer

Female preponderance

Answer

Associated with rheumatoid arthritis

Question 2

Reiter's syndrome is typically characterised by:

Accepted Answer

Urethritis, arthritis and conjunctivitis with or without iridocyclitis

Answer

Urethritis, conjunctivitis and iridocyclitis

Answer

Arthritis, conjunctivitis and iridocyclitis

Answer

All of the above

Question 3

According to the 1987 modified ARA criteria, which joint is NOT involved in Rheumatoid arthritis?

Accepted Answer

Tarsometatarsal

Answer

Knee

Answer

Ankle

Answer

Metatarsophalangeal

Question 4

Which of the following is NOT a characteristic associated with Lupus anticoagulant?

Accepted Answer

Prolonged prothrombin time (PT)

Answer

Increased incidence of abortions

Answer

Arterial thrombosis

Answer

Rashes

Question 5

Hepatitis B is associated with which of the following conditions?

Accepted Answer

Polyarteritis nodosa

Answer

Wegener's granulomatosis

Answer

Systemic lupus erythematosus

Answer

Sjogren syndrome

Question 6

HLA B27 is seen associated with which of the following conditions?

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

Sjogren syndrome

Answer

Scleroderma

Question 7

A 29-year-old male with a history of a long leisure trip presented with right knee pain and a swollen joint. What is the most likely diagnosis?

Accepted Answer

Reiter's disease

Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Bechet's disease

Question 8

Multiple small aneurysms are seen on aortography in which condition?

Accepted Answer

Takayasu's arteritis

Answer

Behcet's syndrome

Answer

Polyarteritis nodosa (PAN)

Answer

Wegener's granulomatosis

Question 9

Erythema marginatum is seen in which of the following conditions?

Accepted Answer

Rheumatic fever

Answer

Drug reactions

Answer

Typhoid fever

Answer

Enteric fever

Question 10

A 29-year-old woman presents with painful swelling of both hands and significant morning stiffness. Physical examination reveals involvement of the proximal interphalangeal and metacarpophalangeal joints. Her rheumatoid factor is positive and antinuclear antibody is negative. Which of the following medications is most likely to improve her joint pain symptoms?

Accepted Answer

NSAID or aspirin

Answer

D-penicillamine

Answer

an antimalarial

Answer

methotrexate

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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