Rheumatology and Immunology Practice Questions

Q: A 20-year-old woman presents with diplopia, syncopal episodes, and paresthesias in both hands (left hand tingling, right hand numbness). Physical examination reveals absent pulses in the right arm. Laboratory findings include an elevated erythrocyte sedimentation rate and thrombocytosis. Angiography demonstrates narrowing and occlusion of multiple arteries, including the right subclavian artery. The patient later develops heart failure and dies from massive pulmonary edema. Autopsy reveals a thickened aorta with vasculitis and fragmentation of elastic fibers. What is the most likely diagnosis?

Takayasu arteritis. **Explanation:** The clinical presentation is classic for **Takayasu Arteritis (TA)**, also known as "Pulseless Disease." **Why Takayasu Arteritis is correct:** TA is a chronic, large-vessel granulomatous vasculitis that primarily affects the **aorta and its main branches** [1]. * **Demographics:** It typically affects young women (<40 years). * **Clinical Features:** The "pulseless" nature (absent right arm pulse), limb claudication/paresthesias, and neurological symptoms (diplopia, syncope due to carotid involvement) are hallmark signs. * **Pathology:** Autopsy findings of a thickened aorta with elastic fiber fragmentation and transmural inflammation are pathognomonic. * **Laboratory:** Elevated ESR and thrombocytosis indicate an active inflammatory state [1]. **Why the other options are incorrect:** * **Buerger Disease (Thromboangiitis obliterans):** Affects small/medium vessels in young male smokers; involves distal extremities (gangrene) rather than the aorta. * **Churg-Strauss (EGPA):** A small-vessel vasculitis characterized by asthma, eosinophilia, and p-ANCA positivity [3]. Biopsy revealed a small-vessel vasculitis with eosinophilic infiltration [3]. * **Kawasaki Disease:** Primarily affects children; involves medium-sized vessels, most notably the coronary arteries, leading to aneurysms [2]. **NEET-PG High-Yield Pearls:** * **Classification:** Large vessel vasculitis (along with Giant Cell Arteritis) [1]. * **Gold Standard Diagnosis:** CT/MR Angiography (shows "string of pearls" appearance or smooth tapering/stenosis). * **Complications:** Aortic regurgitation and renovascular hypertension (due to renal artery stenosis) are common. * **Treatment:** Glucocorticoids are the first-line therapy.

Q: All of the following statements about Churg-Strauss Syndrome are true, except:

Renal failure is common. Churg-Strauss Syndrome, now officially known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, is a small-vessel necrotizing vasculitis characterized by three distinct phases: prodromal (allergic), eosinophilic, and vasculitic [1]. **Why Option C is the correct answer (The Exception):** While EGPA is a systemic vasculitis, **renal involvement is relatively uncommon** and usually less severe compared to other ANCA-associated vasculitides like Granulomatosis with Polyangiitis (GPA) or Microscopic Polyangiitis (MPA) [1]. When it does occur, it typically manifests as focal segmental necrotizing glomerulonephritis, but progression to overt renal failure is rare. **Analysis of Incorrect Options:** * **A. Marked eosinophilia:** This is a hallmark of the disease. Peripheral blood eosinophilia (>10% of total WBC count or >1500/µL) is a primary diagnostic criterion [1]. * **B. Mononeuritis multiplex:** This is the most common clinical manifestation of the vasculitic phase (occurring in up to 75% of patients), typically presenting as foot drop or wrist drop due to involvement of the vasa nervorum [1]. * **D. Allergic rhinitis:** The prodromal phase is almost always characterized by atopy, allergic rhinitis, nasal polyposis, and late-onset asthma. **NEET-PG High-Yield Pearls:** * **ANCA Status:** Only about 40-50% of patients are ANCA positive (usually **p-ANCA/Anti-MPO**) [1]. * **Cardiac Involvement:** This is the **leading cause of mortality** in EGPA (e.g., eosinophilic myocarditis, coronary vasculitis). * **Key Triad:** Asthma + Eosinophilia + Vasculitis. * **Treatment:** Glucocorticoids are the mainstay; Cyclophosphamide is added for severe organ involvement [1].

Q: A young female presented with headache and malaise. Her blood pressure is high and differs by more than 10mm Hg between both upper limbs. The patient is diagnosed with pulseless disease. Which of the following blood vessels is commonly affected in this type of vasculitis?

Renal artery. **Explanation:** The clinical presentation of a young female with headache, hypertension, and a significant blood pressure difference between limbs points toward **Takayasu Arteritis (TA)**, also known as "Pulseless Disease." This is a chronic, large-vessel vasculitis that primarily involves the aorta and its major branches [1]. **1. Why Renal Artery is correct:** In Takayasu Arteritis, the **renal artery** is the most commonly involved branch of the abdominal aorta (occurring in up to 30-60% of cases). Renal artery stenosis leads to activation of the Renin-Angiotensin-Aldosterone System (RAAS), resulting in **renovascular hypertension**, which explains the patient's high blood pressure [2]. **2. Why other options are incorrect:** * **Coeliac axis:** While the coeliac and superior mesenteric arteries can be involved, they are less frequently affected than the renal arteries. * **Coronaries:** Coronary artery involvement (ostial stenosis) occurs in less than 10% of cases and is not a primary diagnostic feature. * **Radial artery:** TA affects large vessels (aorta and its primary branches). The radial artery is a medium-to-small vessel; while the radial *pulse* may be absent due to proximal subclavian or axillary artery stenosis, the radial artery itself is not the primary site of pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females <40 years (Asian descent). * **Vessel Involvement:** The **Subclavian artery** is the most common vessel involved overall (causing the BP discrepancy), but the **Renal artery** is the most common cause of secondary hypertension in these patients. * **Diagnosis:** Gold standard is **Digital Subtraction Angiography (DSA)** or MR Angiography showing "string of pearls" or skip lesions [2]. * **Classification:** It is a **Large Vessel Vasculitis** (along with Giant Cell Arteritis) [1]. * **Treatment:** Glucocorticoids are the first-line therapy.

Q: Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?

Osteoarthritis. The correct answer is **Osteoarthritis (OA)**. This question tests your ability to differentiate joint involvement patterns in common arthritides, a high-yield topic for NEET-PG. **Why Osteoarthritis is correct:** Osteoarthritis typically affects weight-bearing joints and specific joints of the hand. The classic triad of hand involvement in OA includes: 1. **Distal Interphalangeal (DIP) joints:** Presence of Heberden’s nodes [1]. 2. **Proximal Interphalangeal (PIP) joints:** Presence of Bouchard’s nodes [1]. 3. **1st Carpometacarpal (CMC) joint:** Leads to "squaring" of the hand [3]. A hallmark of nodal OA is the **sparing of the wrist** (except for the 1st CMC) and the MCP joints [1]. **Why other options are incorrect:** * **Rheumatoid Arthritis (RA):** RA characteristically involves the MCP and PIP joints but **spares the DIP joints** [3]. Furthermore, wrist involvement is almost universal in RA, unlike the sparing seen in this case. * **Pseudogout (CPPD):** While it can mimic OA, it typically involves the **radiocarpal (wrist) joint** and the MCP joints (especially 2nd and 3rd) [2], often with associated chondrocalcinosis. * **Psoriatic Arthropathy:** While it frequently involves the DIP joints, it is usually associated with dactylitis ("sausage digit"), skin/nail changes, and often involves the wrist in a polyarticular pattern. **NEET-PG Clinical Pearls:** * **DIP Involvement:** Think OA, Psoriatic Arthritis, or Multicentric Reticulohistiocytosis [1]. * **DIP Sparing:** Think Rheumatoid Arthritis [3]. * **1st CMC Joint:** The most common site of OA in the thumb; causes pain during pinch or grip activities [3]. * **Radiology of OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [2].

Q: Which is the best marker of Systemic Lupus Erythematosus (SLE)?

Anti-dsDNA antibodies. The diagnosis and monitoring of Systemic Lupus Erythematosus (SLE) rely on specific serological markers. While **ANA (Antinuclear Antibody)** is the best *screening* test due to its high sensitivity (95-99%) [1], **Anti-dsDNA** is considered the best marker for overall management [2]. **1. Why Anti-dsDNA is the correct answer:** * **High Specificity:** It is highly specific for SLE (>95%). * **Disease Activity:** Unlike other antibodies, its titers fluctuate with disease activity [2]. It is the best marker for monitoring **flares**. * **Organ Involvement:** High titers are strongly associated with **Lupus Nephritis** [1]. **2. Analysis of Incorrect Options:** * **Anti-Sm (Smith) antibodies:** These are the **most specific** markers for SLE [1]. However, they are only present in 20-30% of patients and their levels do not correlate with disease activity, making them less useful for ongoing monitoring than Anti-dsDNA. * **Anti-histone antibodies:** These are the hallmark of **Drug-Induced Lupus** (e.g., caused by Hydralazine, Procainamide, or Isoniazid). * **Anti-Ro (SS-A) antibodies:** These are associated with **Neonatal Lupus** (congenital heart block) and **Sjögren’s syndrome** [1]. **Clinical Pearls for NEET-PG:** * **Best Screening Test:** ANA (High sensitivity, low specificity) [1]. * **Most Specific Test:** Anti-Sm. * **Marker for Monitoring/Nephritis:** Anti-dsDNA [2]. * **Drug-Induced Lupus:** Anti-histone (Note: Anti-dsDNA is usually negative here). * **Complement Levels:** During an active SLE flare (especially renal), **C3 and C4 levels decrease** [2].

Q: All of the following are seen in Rheumatoid arthritis EXCEPT?

Sero-negative arthritis. Explanation: Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory autoimmune disease characterized by symmetric polyarthritis [1]. 1. Why "Sero-negative arthritis" is the correct answer: By definition, Rheumatoid Arthritis is a Sero-positive arthritis. Approximately 70–80% of patients test positive for Rheumatoid Factor (RF) and Anti-Citrullinated Peptide Antibodies (Anti-CCP) [2]. While "seronegative RA" exists clinically, the term "Seronegative Spondyloarthropathies" refers to a distinct group of diseases (like Ankylosing Spondylitis or Psoriatic Arthritis) that are pathophysiologically different from RA. 2. Analysis of Incorrect Options: * Deformities: Chronic, uncontrolled RA leads to joint destruction and characteristic deformities such as Swan-neck deformity, Boutonnière deformity, and Ulnar deviation of the MCP joints. * Mononeuritis Multiplex: This is an extra-articular manifestation of RA caused by Rheumatoid Vasculitis [3]. It involves ischemic damage to peripheral nerves, leading to sensory and motor deficits. * Peri-articular Osteoporosis: This is one of the earliest radiographic hallmarks of RA. Inflammatory cytokines (like TNF-α and IL-6) in the synovium increase osteoclast activity in the bone adjacent to the inflamed joint [4]. Clinical Pearls for NEET-PG: * Most Specific Marker: Anti-CCP (95% specificity) is more specific than RF. * Earliest Sign on X-ray: Soft tissue swelling and peri-articular osteopenia (osteoporosis). * Joint Sparing: RA characteristically spares the Distal Interphalangeal (DIP) joints and the Thoracolumbar spine (except C1-C2) [1]. * Caplan Syndrome: RA associated with pneumoconiosis (coal worker's lung). * Felty Syndrome: Triad of RA, Splenomegaly, and Neutropenia [5].

Question 1

A 20-year-old woman presents with diplopia, syncopal episodes, and paresthesias in both hands (left hand tingling, right hand numbness). Physical examination reveals absent pulses in the right arm. Laboratory findings include an elevated erythrocyte sedimentation rate and thrombocytosis. Angiography demonstrates narrowing and occlusion of multiple arteries, including the right subclavian artery. The patient later develops heart failure and dies from massive pulmonary edema. Autopsy reveals a thickened aorta with vasculitis and fragmentation of elastic fibers. What is the most likely diagnosis?

Accepted Answer

Takayasu arteritis

Answer

Buerger disease

Answer

Churg-Strauss disease

Answer

Kawasaki disease

Question 2

All of the following statements about Churg-Strauss Syndrome are true, except:

Accepted Answer

Renal failure is common

Answer

Marked eosinophilia

Answer

Mononeuritis multiplex is common

Answer

Often associated with allergic rhinitis

Question 3

A young female presented with headache and malaise. Her blood pressure is high and differs by more than 10mm Hg between both upper limbs. The patient is diagnosed with pulseless disease. Which of the following blood vessels is commonly affected in this type of vasculitis?

Accepted Answer

Renal artery

Answer

Coeliac axis

Answer

Coronaries

Answer

Radial artery

Question 4

Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Pseudogout

Answer

Psoriatic arthropathy

Question 5

Which is the best marker of Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Anti-dsDNA antibodies

Answer

Anti-Sm antibodies

Answer

Anti-histone antibodies

Answer

Anti-Ro antibodies

Question 6

All of the following are true regarding Raynaud's phenomenon except?

Accepted Answer

Migratory thrombophlebitis is exclusive for Raynaud's phenomenon

Answer

It involves acral parts of fingers

Answer

Drugs acting by inhibiting beta-receptors in blood vessels also play a role

Answer

Emotional stress may also precipitate Raynaud's phenomenon

Question 7

A 25-year-old woman develops painful swelling of both hands and wrists with morning stiffness. Physical examination reveals erythema, swelling, and joint line tenderness of the proximal interphalangeal, metacarpophalangeal, and wrist joints. Her RF is positive, ANA is negative, and x-rays of the hands show early erosive joint changes. Which of the following medications is most likely to prevent progression of disease?

Accepted Answer

Methotrexate

Answer

D-penicillamine

Answer

Antimalarial

Answer

NSAID or aspirin

Question 8

Which of the following is NOT true regarding reactive arthritis?

Accepted Answer

Keratoderma blennorrhagicum typically occurs on the glans penis.

Answer

HLA-B27 and HIV can affect the severity of reactive arthritis.

Answer

Dactylitis and enthesitis are common manifestations.

Answer

Asymmetrical sacroiliitis is a characteristic finding.

Question 9

All of the following are seen in Rheumatoid arthritis EXCEPT?

Accepted Answer

Sero-negative arthritis

Answer

Deformities

Answer

Mononeuritis multiplex

Answer

Peri-articular osteoporosis

Question 10

Which of the following joints is characteristically involved in rheumatoid arthritis?

Accepted Answer

Metacarpophalangeal joint and proximal interphalangeal joint

Answer

Spine

Answer

Sacroiliac joint

Answer

Wrist joint

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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