Rheumatology and Immunology — MCQs
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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?
All of the following statements about Churg-Strauss Syndrome are true, except:
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?
Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?
Which is the best marker of Systemic Lupus Erythematosus (SLE)?
All of the following are true regarding Raynaud's phenomenon except?
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?
Which of the following is NOT true regarding reactive arthritis?
All of the following are seen in Rheumatoid arthritis EXCEPT?
Which of the following joints is characteristically involved in rheumatoid arthritis?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 211: 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?
- A. Buerger disease
- B. Churg-Strauss disease
- C. Kawasaki disease
- D. Takayasu arteritis (Correct Answer)
Explanation: **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.
Question 212: All of the following statements about Churg-Strauss Syndrome are true, except:
- A. Marked eosinophilia
- B. Mononeuritis multiplex is common
- C. Renal failure is common (Correct Answer)
- D. Often associated with allergic rhinitis
Explanation: 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].
Question 213: 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?
- A. Coeliac axis
- B. Coronaries
- C. Radial artery
- D. Renal artery (Correct Answer)
Explanation: **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.
Question 214: Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?
- A. Rheumatoid arthritis
- B. Pseudogout
- C. Psoriatic arthropathy
- D. Osteoarthritis (Correct Answer)
Explanation: 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].
Question 215: Which is the best marker of Systemic Lupus Erythematosus (SLE)?
- A. Anti-Sm antibodies
- B. Anti-dsDNA antibodies (Correct Answer)
- C. Anti-histone antibodies
- D. Anti-Ro antibodies
Explanation: 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].
Question 216: All of the following are true regarding Raynaud's phenomenon except?
- A. It involves acral parts of fingers
- B. Migratory thrombophlebitis is exclusive for Raynaud's phenomenon (Correct Answer)
- C. Drugs acting by inhibiting beta-receptors in blood vessels also play a role
- D. Emotional stress may also precipitate Raynaud's phenomenon
Explanation: ### Explanation **Raynaud’s Phenomenon (RP)** is an episodic vasospastic disorder of the small cutaneous arteries, typically triggered by cold or emotional stress. **Why Option B is the correct answer (The False Statement):** Migratory thrombophlebitis (Trousseau’s sign of malignancy or Buerger’s disease) is **not** associated with Raynaud’s phenomenon. While both involve vascular pathology, migratory thrombophlebitis involves inflammation and thrombosis of superficial veins, whereas Raynaud’s is a functional vasospastic disorder of the arterioles. There is no clinical or pathological link between the two. **Analysis of Incorrect Options (True Statements):** * **Option A:** RP characteristically involves the **acral parts** (distal extremities), most commonly the fingers and toes, but can also affect the tip of the nose or earlobes. * **Option C:** **Beta-blockers** are a known pharmacological trigger. They cause peripheral vasoconstriction by inhibiting beta-2 mediated vasodilation and leaving alpha-1 mediated vasoconstriction unopposed, thereby worsening or precipitating RP. * **Option D:** The pathophysiology involves an exaggerated sympathetic response; therefore, **emotional stress** is a classic trigger alongside cold exposure. **Clinical Pearls for NEET-PG:** * **The Triphasic Color Change:** Pallor (ischemia) → Cyanosis (deoxygenation) → Rubor (reactive hyperemia). * **Primary vs. Secondary:** Primary RP (Raynaud’s Disease) is idiopathic and usually symmetric. Secondary RP (Raynaud’s Phenomenon) is often asymmetric and associated with connective tissue diseases, most commonly **Systemic Sclerosis (Scleroderma)**. * **Drug of Choice:** Calcium Channel Blockers (e.g., **Nifedipine**) are the first-line treatment. * **Nailfold Capillaroscopy:** A vital bedside test to differentiate primary from secondary RP (dilated/tortuous loops suggest secondary causes).
Question 217: 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?
- A. D-penicillamine
- B. Antimalarial
- C. Methotrexate (Correct Answer)
- D. NSAID or aspirin
Explanation: The clinical presentation—a young woman with symmetrical polyarthritis of small joints (PIP, MCP, wrists), morning stiffness, positive Rheumatoid Factor (RF), and early erosive changes—is diagnostic of **Rheumatoid Arthritis (RA)** [1]. **1. Why Methotrexate is correct:** Methotrexate (MTX) is the **"Anchor Drug"** and the first-line **Disease-Modifying Antirheumatic Drug (DMARD)** for RA [2]. Unlike symptomatic treatments, DMARDs are unique because they have the potential to reduce or prevent joint damage, preserve joint integrity, and arrest the radiological progression of the disease [2]. Given the patient already shows "early erosive changes," immediate initiation of MTX is mandatory to prevent further disability. **2. Why the other options are incorrect:** * **D-penicillamine:** Formerly used for RA, it is now rarely prescribed due to its significant toxicity profile (e.g., nephrotic syndrome, bone marrow suppression) and the availability of more effective agents like MTX. * **Antimalarials (e.g., Hydroxychloroquine):** While these are DMARDs, they are considered "mild" and are generally insufficient as monotherapy for erosive disease. They do not reliably halt the progression of bony erosions when used alone. * **NSAIDs or Aspirin:** These provide rapid symptomatic relief for pain and inflammation but **do not alter the natural history of the disease** or prevent joint destruction/erosions. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Methotrexate is the first-line DMARD for most RA patients [2]. * **Mechanism:** MTX inhibits **dihydrofolate reductase** (at high doses) but acts via **adenosine accumulation** at the low doses used for RA. * **Supplementation:** Always co-prescribe **Folic acid** to reduce side effects like mucosal ulcers and hepatotoxicity [2]. * **Contraindications:** Pregnancy (Teratogenic), Chronic Liver Disease, and significant Renal Impairment. * **Radiology:** The earliest radiographic sign of RA is **juxta-articular osteopenia** (periarticular decalcification).
Question 218: Which of the following is NOT true regarding reactive arthritis?
- A. HLA-B27 and HIV can affect the severity of reactive arthritis.
- B. Dactylitis and enthesitis are common manifestations.
- C. Keratoderma blennorrhagicum typically occurs on the glans penis. (Correct Answer)
- D. Asymmetrical sacroiliitis is a characteristic finding.
Explanation: Reactive arthritis (ReA) is a seronegative spondyloarthropathy that typically follows a gastrointestinal or urogenital infection. [1] **Why Option C is the correct (False) statement:** **Keratoderma blennorrhagicum** consists of hyperkeratotic skin lesions that typically occur on the **palms and soles**. [1] It is clinically and histologically indistinguishable from pustular psoriasis. The characteristic lesion that occurs on the **glans penis** is called **Circinate Balanitis**. [1] Confusing these two distinct mucocutaneous manifestations is a common examiner trap. **Analysis of other options:** * **Option A:** While ReA is triggered by bacteria (e.g., *Chlamydia*, *Salmonella*), the severity and chronicity are significantly increased in **HLA-B27 positive** individuals. [1] Furthermore, ReA can be a presenting feature of **HIV**, often manifesting with more severe, refractory joint involvement. * **Option B:** ReA is characterized by "sausage digits" (**dactylitis**) and inflammation at tendon insertion sites (**enthesitis**, most commonly the Achilles tendon), which are hallmarks of the spondyloarthropathy group. [1] * **Option D:** Unlike Ankylosing Spondylitis (which is usually symmetrical), ReA typically presents with **asymmetrical sacroiliitis** and asymmetric oligoarthritis of the large lower limb joints. [1] **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Urethritis, Conjunctivitis, and Arthritis (seen in only 1/3rd of patients). [1] * **Most common trigger:** *Chlamydia trachomatis* (post-venereal) or *Shigella/Salmonella* (post-enteric). [1] * **Joint Fluid:** Usually sterile (it is an immune-mediated reaction, not a septic arthritis). * **Treatment:** NSAIDs are first-line; DMARDs (Sulfasalazine) are used for chronic cases.
Question 219: All of the following are seen in Rheumatoid arthritis EXCEPT?
- A. Deformities
- B. Mononeuritis multiplex
- C. Peri-articular osteoporosis
- D. Sero-negative arthritis (Correct Answer)
Explanation: 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 220: Which of the following joints is characteristically involved in rheumatoid arthritis?
- A. Spine
- B. Sacroiliac joint
- C. Metacarpophalangeal joint and proximal interphalangeal joint (Correct Answer)
- D. Wrist joint
Explanation: **Explanation:** **Rheumatoid Arthritis (RA)** is a chronic, systemic inflammatory disorder characterized by symmetrical polyarthritis that primarily targets the **synovium** of small joints [1]. **Why Option C is Correct:** The hallmark of RA is the involvement of the small joints of the hands and feet [1]. Specifically, the **Metacarpophalangeal (MCP)** joints and **Proximal Interphalangeal (PIP)** joints are the most characteristic and earliest sites of involvement [1][2]. The inflammation leads to synovial hypertrophy (pannus formation), resulting in the classic "spindle-shaped" swelling of fingers [2]. **Why Other Options are Incorrect:** * **A & B (Spine and Sacroiliac Joint):** These are characteristic of **Seronegative Spondyloarthropathies** (e.g., Ankylosing Spondylitis). RA characteristically **spares** the thoracolumbar spine and the sacroiliac joints. The only part of the spine RA involves is the **Cervical Spine** (specifically the Atlanto-axial joint), which can lead to subluxation [1]. * **D (Wrist Joint):** While the wrist is frequently involved in RA, it is not as "pathognomonic" or specific for the initial diagnosis as the MCP and PIP joints. In a "single best answer" format, the MCP/PIP combination is the classic textbook description. **High-Yield Clinical Pearls for NEET-PG:** 1. **DIP Sparing:** RA characteristically **spares the Distal Interphalangeal (DIP) joints** [1]. DIP involvement suggests Osteoarthritis or Psoriatic Arthritis. 2. **Morning Stiffness:** Lasts >1 hour and improves with activity (unlike Osteoarthritis) [1]. 3. **Deformities:** Look for Ulnar deviation (at MCP), Boutonnière deformity (PIP flexion, DIP hyperextension), and Swan-neck deformity (PIP hyperextension, DIP flexion). 4. **Serology:** Anti-CCP (Cyclic Citrullinated Peptide) is more specific than Rheumatoid Factor (RF) [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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