Rheumatology and Immunology — MCQs

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?

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 201: Which of the following is NOT true regarding Felty's syndrome?

A. Splenomegaly
B. Neutrophilia (Correct Answer)
C. Female preponderance
D. Associated with rheumatoid arthritis

Explanation: **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.

Question 202: Reiter's syndrome is typically characterised by:

A. Urethritis, conjunctivitis and iridocyclitis
B. Arthritis, conjunctivitis and iridocyclitis
C. Urethritis, arthritis and conjunctivitis with or without iridocyclitis (Correct Answer)
D. All of the above

Explanation: **Explanation:** Reiter’s syndrome, now more commonly referred to as **Reactive Arthritis (ReA)**, is a classic clinical triad [1]. It is an autoimmune condition that develops following an infection elsewhere in the body, typically the gastrointestinal (e.g., *Salmonella, Shigella*) or urogenital tract (e.g., *Chlamydia trachomatis*) [1]. **1. Why Option C is correct:** The classic diagnostic triad consists of **Urethritis** (non-gonococcal), **Arthritis** (typically asymmetric, oligoarticular, and involving the lower limbs), and **Conjunctivitis** [1]. While conjunctivitis is the most common ocular manifestation, **Iridocyclitis** (anterior uveitis) occurs in about 20% of cases [2]. Therefore, the presence of iridocyclitis is a recognized feature but not a mandatory component of the primary triad, making Option C the most accurate description. **2. Why other options are incorrect:** * **Option A:** Omits arthritis, which is the hallmark musculoskeletal feature of the syndrome. * **Option B:** Omits urethritis, which represents the primary urogenital trigger/symptom in the classic description. * **Option D:** While these symptoms are related, Option C provides the most precise clinical definition of the syndrome's triad. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** "Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)." * **Genetic Association:** Strongly associated with **HLA-B27** (found in 60–80% of cases) [2]. * **Dermatological Findings:** Look for **Keratoderma blennorrhagicum** (hyperkeratotic skin lesions on palms/soles) and **Circinate balanitis** [1]. * **Joint Involvement:** Often involves the "Sausage digit" (**Dactylitis**) and inflammation at tendon insertion sites (**Enthesitis**, commonly the Achilles tendon) [2].

Question 203: According to the 1987 modified ARA criteria, which joint is NOT involved in Rheumatoid arthritis?

A. Knee
B. Ankle
C. Tarsometatarsal (Correct Answer)
D. Metatarsophalangeal

Explanation: **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.

Question 204: Which of the following is NOT a characteristic associated with Lupus anticoagulant?

A. Increased incidence of abortions
B. Arterial thrombosis
C. Rashes
D. Prolonged prothrombin time (PT) (Correct Answer)

Explanation: 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.

Question 205: Hepatitis B is associated with which of the following conditions?

A. Wegener's granulomatosis
B. Systemic lupus erythematosus
C. Polyarteritis nodosa (Correct Answer)
D. Sjogren syndrome

Explanation: **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.

Question 206: HLA B27 is seen associated with which of the following conditions?

A. Rheumatoid arthritis
B. Ankylosing spondylitis (Correct Answer)
C. Sjogren syndrome
D. Scleroderma

Explanation: **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].

Question 207: 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?

A. Sarcoidosis
B. Tuberculosis
C. Reiter's disease (Correct Answer)
D. Bechet's disease

Explanation: ### 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.

Question 208: Multiple small aneurysms are seen on aortography in which condition?

A. Behcet's syndrome
B. Polyarteritis nodosa (PAN)
C. Takayasu's arteritis (Correct Answer)
D. Wegener's granulomatosis

Explanation: ### Explanation **Correct Answer: C. Takayasu’s Arteritis** **Why it is correct:** Takayasu’s arteritis is a chronic, large-vessel vasculitis that primarily involves the **aorta and its major branches** [1]. The underlying pathology involves granulomatous inflammation of the vessel wall, leading to intimal proliferation and fibrosis. While the most common angiographic findings are **stenosis and occlusions** (leading to its nickname "Pulseless Disease"), the weakening of the arterial media can result in the formation of **multiple aneurysms** (saccular or fusiform) or post-stenotic dilatations. Aortography is the gold standard for visualizing these characteristic "skip lesions," narrowings, and aneurysmal changes throughout the aorta. **Why the other options are incorrect:** * **Polyarteritis nodosa (PAN):** While PAN is famous for "rosary sign" micro-aneurysms, these typically occur in **medium-sized arteries** (e.g., renal, mesenteric, or hepatic arteries). PAN characteristically **spares the aorta** and the venous system [1]. * **Behcet’s Syndrome:** This can cause large vessel aneurysms (notably pulmonary artery aneurysms), but it is a multisystem variable-vessel vasculitis characterized primarily by oral/genital ulcers and uveitis. It does not typically present with the diffuse aortographic pattern seen in Takayasu’s. * **Wegener’s Granulomatosis (GPA):** This is a small-vessel vasculitis. It primarily affects the upper/lower respiratory tract and kidneys (c-ANCA positive). It does not cause macro-aneurysms of the aorta. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females <40 years (Asian descent). * **Classification:** Type I (Branches of aortic arch), Type IIa (Ascending aorta/arch), Type IIb (Thoracic descending aorta), Type III (Thoracic + Abdominal aorta), Type IV (Abdominal aorta/Renal), Type V (Generalized). * **Clinical Sign:** Bruit over the subclavian artery or abdominal aorta and a significant difference (>10 mmHg) in blood pressure between arms. * **Gold Standard Investigation:** Conventional Digital Subtraction Angiography (DSA).

Question 209: Erythema marginatum is seen in which of the following conditions?

A. Drug reactions
B. Typhoid fever
C. Enteric fever
D. Rheumatic fever (Correct Answer)

Explanation: 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 210: 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?

A. D-penicillamine
B. an antimalarial
C. methotrexate
D. NSAID or aspirin (Correct Answer)

Explanation: The clinical presentation—a young woman with symmetric polyarthritis of the small joints (PIP and MCP) and significant morning stiffness—is classic for **Rheumatoid Arthritis (RA)** [1]. **1. Why the correct answer is right:** The question asks which medication is most likely to improve her **joint pain symptoms**. In the management of RA, medications are divided into those that provide **symptomatic relief** and those that modify the disease course (DMARDs) [2]. **NSAIDs and Aspirin** are the first-line agents for rapid reduction of pain and inflammation by inhibiting prostaglandin synthesis [1]. While they do not prevent joint destruction, they are the most effective among the choices for immediate symptomatic control [1]. **2. Why the incorrect options are wrong:** * **Methotrexate (C):** This is the "Gold Standard" and first-line **Disease-Modifying Antirheumatic Drug (DMARD)** [2]. While essential for long-term management to prevent joint erosions, it has a slow onset of action (taking 4–6 weeks to work) and is not used for immediate symptomatic pain relief. * **Antimalarials (B) (e.g., Hydroxychloroquine):** These are mild DMARDs used in very early or mild RA. Like methotrexate, they have a delayed onset of action and are insufficient for acute pain management. * **D-penicillamine (A):** This is an older, "second-line" DMARD rarely used today due to its significant side-effect profile (e.g., nephrotic syndrome, drug-induced lupus). It does not provide immediate pain relief. **Clinical Pearls for NEET-PG:** * **Initial Management:** Always start a DMARD (usually Methotrexate) as soon as RA is diagnosed, but bridge the patient with **NSAIDs or low-dose Glucocorticoids** for immediate symptom control [2]. * **Joint Sparing:** RA typically spares the **Distal Interphalangeal (DIP)** joints; involvement of DIP suggests Osteoarthritis or Psoriatic Arthritis [1]. * **Most Specific Marker:** While Rheumatoid Factor is sensitive, **Anti-CCP (Cyclic Citrullinated Peptide)** antibodies are the most specific marker for RA and predict aggressive disease [1].

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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