Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT a feature of Lofgren syndrome?

Uveitis. **Explanation:** Lofgren syndrome is a specific, acute clinical presentation of **Sarcoidosis** characterized by a classic triad. It typically has a benign course with a high rate of spontaneous remission [1]. **1. Why Uveitis is the correct answer:** While uveitis is a common manifestation of systemic sarcoidosis (occurring in about 25-50% of cases), it is **not** part of the defined diagnostic triad for Lofgren syndrome [1]. Lofgren syndrome is specifically defined by the presence of **Erythema Nodosum (EN), Bilateral Hilar Lymphadenopathy (BHL), and Joint involvement.** **2. Analysis of incorrect options:** * **B. Erythema nodosum:** This is a hallmark cutaneous finding of Lofgren syndrome, more commonly seen in women [1]. It presents as painful, erythematous nodules on the shins. * **C. Polyarthritis:** Migratory polyarthritis, particularly involving the **ankle joints**, is a core component [1]. In men, periarthritis of the ankles may sometimes occur in the absence of EN. * **D. Bilateral hilar adenopathy:** This is the classic radiographic finding required for diagnosis [1]. It is usually asymptomatic and found on a routine chest X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Prognosis:** Lofgren syndrome carries an excellent prognosis (>90% resolution within 2 years) compared to other forms of sarcoidosis. * **Heerfordt Syndrome (Uveoparotid Fever):** Do not confuse Lofgren with Heerfordt syndrome, which *does* include **Uveitis**, along with Parotid enlargement, Fever, and Facial nerve palsy. * **HLA Association:** Strongly associated with **HLA-DRB1*03**. * **Treatment:** Primarily symptomatic with NSAIDs; systemic steroids are rarely needed unless severe.

Q: Which one of the following is not included in Jones's Major criteria?

High ESR. The **Jones Criteria** are used to diagnose the first episode of **Acute Rheumatic Fever (ARF)**, a non-suppurative sequela of Group A Streptococcal pharyngeal infection [1]. The criteria are divided into **Major** and **Minor** categories. ### Why High ESR is the Correct Answer **High ESR (Erythrocyte Sedimentation Rate)** is a **Minor criterion**, not a Major one. Minor criteria represent non-specific systemic signs of inflammation and include: * **Clinical:** Fever, Polyarthralgia. * **Laboratory:** Elevated acute phase reactants (ESR ≥ 60 mm/h or CRP ≥ 3.0 mg/dL), Prolonged PR interval on ECG. ### Why the Other Options are Incorrect Options A, B, and C are all **Major criteria** (Mnemonic: **J♥NES**): * **Pancarditis (J - Joint/Carditis):** Clinical or subclinical evidence of carditis (valvulitis, myocarditis, or pericarditis) [1]. * **Chorea (N - Nodes/Chorea):** Specifically **Sydenham’s chorea** (St. Vitus Dance), characterized by rapid, purposeless movements. * **Subcutaneous Nodules (S - Subcutaneous):** Small, painless, firm nodules usually found over bony prominences or tendons. * *Note: The other major criteria are **Polyarthritis** and **Erythema Marginatum**.* ### NEET-PG High-Yield Pearls 1. **Diagnosis Requirement:** 2 Major OR 1 Major + 2 Minor criteria, PLUS evidence of preceding Strep infection [1]. 2. **Exception:** Chorea or indolent carditis can be diagnostic of ARF on their own without evidence of preceding infection [1]. 3. **Joint Involvement:** In low-risk populations, only **Polyarthritis** is major; however, in high-risk populations (like India), **Monoarthritis** or **Polyarthralgia** can be considered Major criteria under the revised Jones criteria. 4. **Most Common Manifestation:** Migratory Polyarthritis. 5. **Most Serious Manifestation:** Carditis (leads to chronic rheumatic heart disease) [2].

Q: Which is the most common site of subcutaneous nodules in rheumatoid arthritis?

Elbow. **Explanation:** Rheumatoid nodules are the most common extra-articular manifestation of Rheumatoid Arthritis (RA), occurring in approximately 20–30% of patients, typically those who are Rheumatoid Factor (RF) positive [1]. **1. Why the Elbow is Correct:** Subcutaneous nodules in RA have a predilection for **pressure points** and **extensor surfaces**. The **olecranon process (elbow)** is the most common site because it is frequently subjected to mechanical stress and repetitive minor trauma [1]. Histologically, these nodules consist of a central area of fibrinoid necrosis surrounded by palisading macrophages and a peripheral layer of connective tissue. **2. Analysis of Incorrect Options:** * **Wrist:** While RA frequently involves the wrist joints (synovitis), subcutaneous nodules are less common here compared to the olecranon. * **Achilles Tendon:** This is a classic site for **Xanthomas** (in hyperlipidemia) or nodules in Gout (tophi), but it is not the primary site for RA nodules. * **Occiput:** This is a common site for pressure sores in bedbound patients or nodules in Rheumatic Fever (though rare), but it is not the most frequent site in RA. **3. Clinical Pearls for NEET-PG:** * **Serology:** Rheumatoid nodules are strongly associated with **RF positivity** and **anti-CCP antibodies**. Their presence often indicates more severe systemic disease. * **Methotrexate-induced accelerated nodulosis:** Occasionally, patients on Methotrexate therapy may experience a paradoxical increase in small nodules, typically on the fingers. * **Differential Diagnosis:** Always differentiate RA nodules from **Gouty Tophi** (which may ulcerate and discharge chalky material) and **Basal Cell Carcinoma** (if located on the face). * **Internal Sites:** Though rare, nodules can occur in the lungs (Caplan syndrome), heart valves, or sclera (scleromalacia perforans) [1].

Q: Reiter's syndrome is associated with which of the following causative agents?

Chlamydia. **Explanation:** **Reiter’s Syndrome**, now more commonly referred to as **Reactive Arthritis (ReA)**, is an asymmetric inflammatory polyarthritis that develops following an extra-articular infection, typically of the gastrointestinal (GI) or urogenital (UG) tract [1]. 1. **Why Chlamydia is Correct:** * *Chlamydia trachomatis* is the most common cause of **urogenital** reactive arthritis worldwide [1]. It is an obligate intracellular pathogen. The immune system triggers a cross-reactive response (molecular mimicry) against the joints following the primary infection. * Classic Reiter’s Syndrome is defined by the clinical triad: **Urethritis, Conjunctivitis, and Arthritis** ("Can't see, can't pee, can't climb a tree") [1]. 2. **Why the other options are incorrect:** * **Neisseria:** While *N. gonorrhoeae* causes "Gonococcal Arthritis," this is a **septic arthritis** (direct joint infection) rather than a reactive one. Reactive arthritis is, by definition, sterile. * **Mycoplasma:** Although *Mycoplasma genitalium* can cause urethritis, it is a rare and inconsistent trigger for the full Reiter’s triad compared to Chlamydia. * **Herpes virus:** Viral infections (like B19 or Rubella) cause viral arthritis, but they are not associated with the specific pathophysiology or triad of Reiter’s Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Association:** Strongly associated with **HLA-B27** (positive in ~80% of cases) [1]. * **Other Triggers (Enteric):** *Shigella flexneri*, *Salmonella*, *Campylobacter*, and *Yersinia* [1]. * **Cutaneous Manifestations:** Look for **Keratoderma blennorrhagicum** (vesicular palm/sole rash) and **Circinate balanitis** [1]. * **Treatment:** NSAIDs are first-line; antibiotics treat the underlying infection but do not always resolve the arthritis.

Q: A lady presents with right knee swelling. Aspiration revealed the presence of calcium pyrophosphate dihydrate (CPPD) crystals. What is the next best investigation?

Thyroid-stimulating hormone (TSH). **Explanation:** The presence of **calcium pyrophosphate dihydrate (CPPD)** crystals in joint aspirate confirms the diagnosis of **Pseudogout**. Unlike primary gout, pseudogout is frequently associated with underlying metabolic and endocrine disorders [1]. **Why TSH is the correct investigation:** Hypothyroidism is a well-established metabolic trigger for CPPD deposition. When a patient presents with pseudogout, it is mandatory to screen for reversible or manageable metabolic associations. The "Big Four" associations to screen for in CPPD are: 1. **Hypothyroidism** (hence, TSH is the next best step). 2. **Hyperparathyroidism** (check Calcium/PTH). 3. **Hemochromatosis** (check Ferritin/Iron studies) [3]. 4. **Hypomagnesemia.** **Analysis of Incorrect Options:** * **A & B (ANA and RF):** These are markers for systemic autoimmune diseases like SLE and Rheumatoid Arthritis. While these can coexist with joint swelling, they do not have a direct causal link with the formation of CPPD crystals. * **C (CPK):** This is a marker for muscle injury or inflammatory myositis (e.g., Dermatomyositis) [2]. It has no diagnostic value in crystal-induced arthropathies. **Clinical Pearls for NEET-PG:** * **Radiology:** Look for **Chondrocalcinosis** (linear calcification of articular cartilage), most commonly seen in the knee (meniscus) and wrist (triangular fibrocartilage). * **Microscopy:** CPPD crystals are **rhomboid-shaped** and show **weak positive birefringence** under polarized light (unlike the needle-shaped, strongly negative birefringent crystals of gout). * **Commonest Site:** The **Knee** is the most common joint involved in pseudogout (Gout favors the 1st MTP joint) [1]. * **Treatment:** Acute management involves NSAIDs, Colchicine, or intra-articular steroids. Always treat the underlying metabolic cause.

Q: Which antibody is associated with a decreased risk of nephritis in patients with Systemic Lupus Erythematosus?

Anti-SSA. Explanation: In Systemic Lupus Erythematosus (SLE), the presence of **Anti-SSA (Ro) antibodies** is statistically associated with a **decreased risk of developing lupus nephritis**. While these antibodies are linked to specific manifestations like photosensitivity, subacute cutaneous lupus (SCLE), and Sjögren’s syndrome [1], patients positive for Anti-SSA often follow a more "benign" renal course compared to those with other serological markers. **Analysis of Options:** * **Anti-SSA (Correct):** Associated with a lower incidence of renal involvement [1]. However, it is highly associated with **Neonatal Lupus** (congenital heart block) and **Subacute Cutaneous Lupus Erythematosus (SCLE)** [1]. * **Anti-dsDNA (Incorrect):** This is the hallmark antibody for **Lupus Nephritis**. Its titers correlate with disease activity and the development of glomerulonephritis [1]. * **Anti-Smith (Incorrect):** The most specific antibody for SLE. It is strongly associated with **renal disease** and central nervous system (CNS) involvement [1]. * **Anti-histone (Incorrect):** The classic marker for **Drug-Induced Lupus (DILE)**. Renal and CNS involvement are characteristically rare in DILE, but the antibody itself is not considered "protective" against nephritis in idiopathic SLE. **High-Yield Clinical Pearls for NEET-PG:** * **Most Specific Antibody for SLE:** Anti-Smith [1]. * **Best Screening Test:** ANA (High sensitivity, low specificity) [1]. * **Antibody correlating with Disease Activity:** Anti-dsDNA [1]. * **Antibody in Neonatal Lupus:** Anti-SSA/Ro and Anti-SSB/La. * **Drug-Induced Lupus:** Anti-histone positive; Anti-dsDNA and Anti-Smith are typically negative. Common triggers include Hydralazine, Procainamide, and Isoniazid.

Question 1

Which of the following is NOT a feature of Lofgren syndrome?

Accepted Answer

Uveitis

Answer

Erythema nodosum

Answer

Polyarthritis

Answer

Bilateral hilar adenopathy

Question 2

An 80-year-old female presented with soreness in both shoulders and upper back, constant fatigue, and persistent headaches for the past few days. She was managed conservatively. Three days later, she presented with sudden loss of vision in the left eye. Ophthalmoscopic examination was performed. What is the next best appropriate step in the management of this condition?

Accepted Answer

Initiate high-dose glucocorticoid therapy and refer for temporal artery biopsy

Answer

Brain MRI to evaluate for demyelinating disease or tumor

Answer

Ocular massage for 2 minutes followed by repeat visual acuity testing

Answer

Topical beta-blocker administration

Question 3

A 30-year-old woman presents with hemoptysis, epistaxis, and decreased urine output. Nasal mucosal ulcers were seen on inspection. Chest X-ray shows three cavitary lesions. She is positive for ANCA. What is the most likely diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Goodpasture's syndrome

Answer

Berger's nephropathy

Answer

Alport's disease

Question 4

A 40-year-old female patient presented with bilateral joint pain in the wrists, and the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. The involved joints were tender and swollen. The patient also reported a history of certain skin lesions that occurred before the joint involvement, along with certain nail changes. Laboratory findings revealed HLA-B27 positivity. Which of the following X-ray findings most commonly correlates with the above condition?

Accepted Answer

Erosive changes with joint space narrowing

Answer

Periostitis and proliferative changes

Answer

Saw-tooth appearance of the joints

Answer

All of the above findings are seen.

Question 5

Which one of the following is not included in Jones's Major criteria?

Accepted Answer

High ESR

Answer

Pancarditis

Answer

Chorea

Answer

Subcutaneous nodule

Question 6

Which is the most common site of subcutaneous nodules in rheumatoid arthritis?

Accepted Answer

Elbow

Answer

Wrist

Answer

Achilles tendon

Answer

Occiput

Question 7

A 48-year-old man complains of joint pain and stiffness for the past three months. All of the following are evidence of the diagnosis of rheumatoid arthritis (RA), EXCEPT?

Accepted Answer

Synovial fluid with high viscosity and 30,000 lymphocytes/mm3

Answer

Early morning stiffness lasting one hour

Answer

Numbness and blanching of fingers on exposure to cold

Answer

Symmetrical involvement of the metacarpophalangeal joints

Question 8

Reiter's syndrome is associated with which of the following causative agents?

Accepted Answer

Chlamydia

Answer

Neisseria

Answer

Mycoplasma

Answer

Herpes virus

Question 9

A lady presents with right knee swelling. Aspiration revealed the presence of calcium pyrophosphate dihydrate (CPPD) crystals. What is the next best investigation?

Accepted Answer

Thyroid-stimulating hormone (TSH)

Answer

Antinuclear antibody (ANA)

Answer

Rheumatoid factor (RF)

Answer

Creatine phosphokinase (CPK)

Question 10

Which antibody is associated with a decreased risk of nephritis in patients with Systemic Lupus Erythematosus?

Accepted Answer

Anti-SSA

Answer

Anti-dsDNA

Answer

Anti-Smith

Answer

Anti-histone

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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