Rheumatology and Immunology — MCQs
On this page
Which of the following is NOT a feature of Lofgren syndrome?
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?
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?
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?
Which one of the following is not included in Jones's Major criteria?
Which is the most common site of subcutaneous nodules in rheumatoid arthritis?
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?
Reiter's syndrome is associated with which of the following causative agents?
A lady presents with right knee swelling. Aspiration revealed the presence of calcium pyrophosphate dihydrate (CPPD) crystals. What is the next best investigation?
Which antibody is associated with a decreased risk of nephritis in patients with Systemic Lupus Erythematosus?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 241: Which of the following is NOT a feature of Lofgren syndrome?
- A. Uveitis (Correct Answer)
- B. Erythema nodosum
- C. Polyarthritis
- D. Bilateral hilar adenopathy
Explanation: **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.
Question 242: 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?
- A. Brain MRI to evaluate for demyelinating disease or tumor
- B. Initiate high-dose glucocorticoid therapy and refer for temporal artery biopsy (Correct Answer)
- C. Ocular massage for 2 minutes followed by repeat visual acuity testing
- D. Topical beta-blocker administration
Explanation: The clinical presentation of an elderly patient with shoulder/back soreness (suggestive of **Polymyalgia Rheumatica**), persistent headaches, and sudden vision loss is classic for **Giant Cell Arteritis (GCA)** or Temporal Arteritis. The sudden loss of vision is a medical emergency caused by **Anterior Ischemic Optic Neuropathy (AION)** due to vasculitis of the posterior ciliary arteries. **1. Why Option B is Correct:** In GCA, the risk of permanent bilateral blindness is high. Therefore, **immediate initiation of high-dose systemic glucocorticoids** (e.g., IV methylprednisolone or high-dose oral prednisolone) is mandatory to prevent vision loss in the contralateral eye [1]. Treatment should **never be delayed** while waiting for diagnostic results [1]. A temporal artery biopsy remains the gold standard for confirmation but should be performed after starting steroids [1]. **2. Why Other Options are Incorrect:** * **Option A:** While headaches and vision loss can occur in CNS pathologies, the systemic symptoms (shoulder pain/fatigue) and age strongly point toward GCA rather than a tumor or MS. * **Option C:** Ocular massage is a maneuver used for **Central Retinal Artery Occlusion (CRAO)** to dislodge an embolus. It does not address the underlying inflammatory vasculitis of GCA. * **Option D:** Topical beta-blockers are used to lower intraocular pressure in glaucoma, which is not the cause of sudden, painless vision loss in this systemic inflammatory context [2]. **Clinical Pearls for NEET-PG:** * **Association:** ~50% of GCA patients have Polymyalgia Rheumatica (PMR) [1]. * **Diagnosis:** Elevated ESR (often >100 mm/hr) and CRP are highly sensitive. Rarely, PMR and GCA can present with a normal ESR [1]. * **Gold Standard:** Temporal artery biopsy (look for "skip lesions"; hence a long segment is needed) [1]. * **Treatment:** Start steroids immediately to save the "other eye." If visual loss is present, pulse IV steroids are often preferred [1].
Question 243: 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?
- A. Goodpasture's syndrome
- B. Wegener's granulomatosis (Correct Answer)
- C. Berger's nephropathy
- D. Alport's disease
Explanation: ### Explanation The clinical presentation of **hemoptysis** (pulmonary involvement), **epistaxis/nasal ulcers** (upper respiratory tract involvement), and **decreased urine output** (renal involvement) describes a classic **Pulmonary-Renal Syndrome** [1]. **Why Wegener’s Granulomatosis (Granulomatosis with Polyangiitis - GPA) is correct:** GPA is a small-vessel vasculitis characterized by a "triad" of upper respiratory tract, lower respiratory tract, and renal involvement (pauci-immune glomerulonephritis) [1]. * **Upper Respiratory:** Nasal mucosal ulcers, epistaxis, and saddle-nose deformity are hallmark features [2]. * **Lower Respiratory:** Chest X-ray typically shows **cavitary nodules**, which is a high-yield distinguishing feature [2]. * **Serology:** It is strongly associated with **c-ANCA (PR3-ANCA)** [1]. **Why the other options are incorrect:** * **Goodpasture’s Syndrome:** While it presents with pulmonary hemorrhage and glomerulonephritis, it **spares the upper respiratory tract** (no nasal ulcers) and is associated with **Anti-GBM antibodies**, not ANCA [2]. * **Berger’s Nephropathy (IgA Nephropathy):** This typically presents as episodic gross hematuria following an upper respiratory infection (synpharyngitic hematuria). It does not cause cavitary lung lesions or nasal ulcers. * **Alport’s Disease:** A genetic collagen disorder presenting with hereditary nephritis, sensorineural hearing loss, and ocular defects (lenticonus). It does not present with vasculitic features or ANCA positivity. **NEET-PG High-Yield Pearls:** * **GPA Triad:** Upper Respiratory + Lower Respiratory + Glomerulonephritis. * **Imaging:** Cavitary lesions on CXR/CT are highly suggestive of GPA over other vasculitides [2]. * **Marker:** c-ANCA (Proteinase-3) is the most specific marker. * **Biopsy:** Shows necrotizing granulomatous inflammation [2]. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab) [1].
Question 244: 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?
- A. Erosive changes with joint space narrowing (Correct Answer)
- B. Periostitis and proliferative changes
- C. Saw-tooth appearance of the joints
- D. All of the above findings are seen.
Explanation: ### **Explanation** The clinical presentation describes a 40-year-old female with inflammatory polyarthritis involving the **DIP joints**, skin lesions, nail changes, and **HLA-B27 positivity**. This triad is classic for **Psoriatic Arthritis (PsA)** [1]. **1. Why Option A is correct:** While PsA is known for unique features like bone formation, it is primarily an **inflammatory erosive arthritis**. The hallmark radiographic findings include marginal **erosions** and **joint space narrowing** [1]. In the early to mid-stages of the disease, these destructive changes are the most common findings seen on X-ray, often progressing to the classic "pencil-in-cup" deformity (where an erosion tapers one bone end to fit into the widened base of the adjacent bone) [1]. **2. Why other options are incorrect:** * **Option B:** Periostitis (new bone formation) and proliferative changes are indeed characteristic of PsA (unlike Rheumatoid Arthritis), but they are often secondary to or concurrent with the primary erosive process. * **Option C:** "Saw-tooth" appearance refers to the irregular, jagged joint surface caused by small marginal erosions. While seen in PsA, it is a specific descriptive subset of erosive changes. * **Option D:** While all these findings *can* be seen in PsA, the question asks for the finding that **most commonly correlates** with the condition's progression. Erosive changes and joint space narrowing are the fundamental radiographic markers of inflammatory joint destruction in PsA. ### **Clinical Pearls for NEET-PG** * **DIP Involvement:** PsA is one of the few inflammatory arthritides that involves the **DIP joints** (RA typically spares them) [1]. * **Moll and Nalebuff Criteria:** Recognizes five patterns of PsA: Asymmetric oligoarthritis (most common), Symmetrical polyarthritis (RA-like), DIP involvement, Arthritis mutilans, and Spondyloarthropathy [1]. * **Nail Changes:** Pitting, onycholysis, and subungual hyperkeratosis are strong predictors of joint involvement [1]. * **Radiology "Buzzwords":** Pencil-in-cup deformity, "Telescoping" of digits (Arthritis mutilans), and fluffy periostitis [1].
Question 245: Which one of the following is not included in Jones's Major criteria?
- A. Pancarditis
- B. Chorea
- C. Subcutaneous nodule
- D. High ESR (Correct Answer)
Explanation: 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].
Question 246: Which is the most common site of subcutaneous nodules in rheumatoid arthritis?
- A. Elbow (Correct Answer)
- B. Wrist
- C. Achilles tendon
- D. Occiput
Explanation: **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].
Question 247: 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?
- A. Early morning stiffness lasting one hour
- B. Numbness and blanching of fingers on exposure to cold
- C. Symmetrical involvement of the metacarpophalangeal joints
- D. Synovial fluid with high viscosity and 30,000 lymphocytes/mm3 (Correct Answer)
Explanation: The correct answer is **D**. In Rheumatoid Arthritis (RA), the synovial fluid is **inflammatory**, not non-inflammatory. Inflammatory joint fluid is characterized by **low viscosity** (due to the breakdown of hyaluronate by enzymes) and a high white cell count (typically 5,000–50,000 cells/mm³). Crucially, the predominant cells in RA synovial fluid are **neutrophils** (often >50%), not lymphocytes. High viscosity is typical of normal or osteoarthritic fluid. [1] **Analysis of other options:** * **Option A:** Early morning stiffness lasting >1 hour is a classic hallmark of inflammatory arthritis like RA, reflecting the "gel phenomenon" where inflammatory exudate accumulates during rest. [1] * **Option B:** Raynaud’s phenomenon (numbness/blanching) can occur in RA as an extra-articular manifestation or as part of an overlap syndrome, though it is more common in Scleroderma or SLE. * **Option C:** Symmetrical involvement of small joints (MCPs, PIPs, MTPs) is the pathognomonic distribution of RA, distinguishing it from the asymmetrical involvement seen in seronegative spondyloarthropathies. [1] **High-Yield Clinical Pearls for NEET-PG:** * **RA Synovial Fluid:** Turbid, low viscosity, WBC 5,000–50,000/mm³, >50% PMNs, and low glucose compared to serum. * **Joint Sparing:** RA characteristically **spares the Distal Interphalangeal (DIP) joints** (unlike Osteoarthritis and Psoriatic Arthritis). * **Most Specific Marker:** Anti-Cyclic Citrullinated Peptide (Anti-CCP) antibodies (95% specificity). [1] * **First-line DMARD:** Methotrexate is the gold standard for initial therapy.
Question 248: Reiter's syndrome is associated with which of the following causative agents?
- A. Chlamydia (Correct Answer)
- B. Neisseria
- C. Mycoplasma
- D. Herpes virus
Explanation: **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.
Question 249: A lady presents with right knee swelling. Aspiration revealed the presence of calcium pyrophosphate dihydrate (CPPD) crystals. What is the next best investigation?
- A. Antinuclear antibody (ANA)
- B. Rheumatoid factor (RF)
- C. Creatine phosphokinase (CPK)
- D. Thyroid-stimulating hormone (TSH) (Correct Answer)
Explanation: **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.
Question 250: Which antibody is associated with a decreased risk of nephritis in patients with Systemic Lupus Erythematosus?
- A. Anti-SSA (Correct Answer)
- B. Anti-dsDNA
- C. Anti-Smith
- D. Anti-histone
Explanation: 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.
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
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free