Rheumatology and Immunology — MCQs
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Renal involvement is usually absent in which of the following conditions?
A 63-year-old man presents to the emergency room with severe pain and swelling in his right knee. The pain started suddenly, and there is no history of injury to the knee. On physical examination, the knee is warm, red, and swollen with decreased range of movement. A diagnostic aspiration of the knee is performed. Which of the following findings will most likely distinguish pseudogout from gout?
Which metacarpophalangeal (MC) joint is commonly involved in gout?
Aortic arch syndrome is also known as:
Which of the following conditions typically spares the joints of the hand?
Bridge therapy is employed in which of the following conditions?
Which of the following conditions is associated with anti-proteinase-3 positivity?
All of the following are true about Temporal Arteritis except?
A 27-year-old male presents with burning micturition and urethral discharge. After 4 weeks, he develops joint pains involving both knees and ankles, redness of the eyes, and skin lesions. What is the most probable clinical diagnosis?
Which of the following statements is not true about Gout?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 251: Renal involvement is usually absent in which of the following conditions?
- A. Drug-induced systemic lupus erythematosus (SLE) (Correct Answer)
- B. Adult SLE
- C. Pediatric SLE
- D. SLE during pregnancy
Explanation: **Explanation:** The correct answer is **Drug-induced systemic lupus erythematosus (SLE)**. **1. Why Drug-induced SLE is the correct answer:** Drug-induced SLE (DILE) is a syndrome that shares clinical features with idiopathic SLE but is triggered by specific medications (e.g., Hydralazine, Procainamide, Isoniazid). A hallmark of DILE is its **mild clinical course**. Unlike idiopathic SLE, DILE characteristically **spares the kidneys and the Central Nervous System (CNS)**. It typically presents with constitutional symptoms, arthralgia, and serositis. Laboratory findings show **Anti-histone antibodies** in >95% of cases, while Anti-dsDNA and low complement levels (C3, C4) are rare [1]. **2. Why the other options are incorrect:** * **Adult SLE:** Renal involvement (Lupus Nephritis) occurs in approximately 40–50% of adult patients and is a major cause of morbidity and mortality [1]. * **Pediatric SLE:** Childhood-onset SLE tends to be **more aggressive** than adult-onset disease. Renal involvement is more frequent (up to 80%) [2] and often more severe at presentation. * **SLE during Pregnancy:** Pregnancy can trigger flares of SLE. Lupus nephritis is a significant concern during pregnancy as it mimics pre-eclampsia and increases the risk of adverse maternal and fetal outcomes. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common drug causing DILE:** Procainamide (highest risk), but Hydralazine is more commonly used clinically. * **Genetic Predisposition:** "Slow acetylators" are at a higher risk of developing DILE. * **Key Lab Marker:** Anti-histone antibodies (High sensitivity for DILE) [3]. * **Management:** Symptoms usually resolve within weeks of discontinuing the offending drug. * **Mnemonic for DILE drugs (HIP):** **H**ydralazine, **I**soniazid, **P**rocainamide (also Phenytoin, Penicillamine).
Question 252: A 63-year-old man presents to the emergency room with severe pain and swelling in his right knee. The pain started suddenly, and there is no history of injury to the knee. On physical examination, the knee is warm, red, and swollen with decreased range of movement. A diagnostic aspiration of the knee is performed. Which of the following findings will most likely distinguish pseudogout from gout?
- A. Needle-shaped, negatively birefringent crystals on polarized microscopy (Correct Answer)
- B. Needle-shaped, positively birefringent crystals on polarized microscopy
- C. Rhomboid-shaped, negatively birefringent crystals on polarized microscopy
- D. Rhomboid-shaped, positively birefringent crystals on polarized microscopy
Explanation: ### Explanation The clinical presentation of sudden onset, severe monoarthritis in an elderly patient is characteristic of **Crystal-Induced Arthropathies**. [1], [2] The gold standard for distinguishing between Gout and Pseudogout (Calcium Pyrophosphate Deposition Disease - CPPD) is **compensated polarized light microscopy** of the synovial fluid. **1. Why the Correct Answer is Right:** The question asks for the finding that distinguishes the two. **Gout** is caused by the deposition of Monosodium Urate (MSU) crystals. [2] These are characteristically **needle-shaped** and exhibit **strong negative birefringence** (they appear yellow when aligned parallel to the slow axis of the compensator). Identifying these crystals confirms Gout and rules out Pseudogout. **2. Analysis of Incorrect Options:** * **Option B:** Needle-shaped, positively birefringent crystals do not correspond to any common clinical crystal arthropathy. * **Option C:** While Pseudogout crystals are rhomboid, they are **positively** birefringent, not negative. * **Option D:** This describes **Pseudogout (CPPD)**. CPPD crystals are **rhomboid or brick-shaped** and show **weak positive birefringence** (appearing blue when parallel to the compensator). While this is a finding in pseudogout, the question asks for the finding that distinguishes it *from* gout based on the provided options. [1] **3. High-Yield Clinical Pearls for NEET-PG:** * **Gout (MSU):** "Yellow/Parallel/Negative" (mnemonic: **YPN**). Associated with hyperuricemia, alcohol, and red meat. [3] * **Pseudogout (CPPD):** "Blue/Parallel/Positive" (mnemonic: **BPP**). Often associated with hyperparathyroidism, hemochromatosis, and hypomagnesemia. [1] * **Radiology:** Gout shows "punched-out" erosions with overhanging edges (Martel’s sign); Pseudogout shows **chondrocalcinosis** (linear calcification of articular cartilage). [2] * **Common Site:** Gout most commonly affects the 1st MTP joint (Podagra); Pseudogout most commonly affects the **Knee**. [1]
Question 253: Which metacarpophalangeal (MC) joint is commonly involved in gout?
- A. Knee
- B. Hip
- C. Metacarpophalangeal joint of the big toe (Correct Answer)
- D. Metacarpophalangeal joint of the thumb
Explanation: **Explanation:** Gout is a crystal-induced arthropathy caused by the deposition of **monosodium urate (MSU) crystals** in joints and tissues [3]. The most characteristic clinical presentation of acute gout is **Podagra**, which refers to the involvement of the **first metatarsophalangeal (MTP) joint** (the big toe) [2]. *Note: The question uses the term "metacarpophalangeal" (MCP), which typically refers to the hand; however, in the context of the big toe and standard medical examinations like NEET-PG, this refers to the **1st MTP joint**.* **Why the Big Toe?** The 1st MTP joint is the most common site (involved in ~50% of initial attacks) due to: 1. **Lower Temperature:** Urate solubility decreases in peripheral, cooler joints. 2. **Repeated Microtrauma:** The joint bears significant weight and stress during walking. **Analysis of Incorrect Options:** * **Knee:** While the knee is the second most common site for gout, it is more frequently associated with **Pseudogout** (Calcium Pyrophosphate Deposition Disease). * **Hip:** Gout rarely involves large, axial, or proximal joints like the hip. Involvement of the hip should prompt a search for alternative diagnoses. * **Thumb:** While gout can affect the small joints of the hand (especially in chronic tophaceous gout), it is significantly less common as an initial presentation compared to the big toe [4]. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Polarized light microscopy showing **needle-shaped, negatively birefringent** crystals (yellow when parallel to the axis). * **Radiology:** Look for **"Punched-out" erosions** with overhanging edges (Martel’s sign). * **Acute Management:** NSAIDs (first-line), Colchicine, or Corticosteroids. * **Chronic Management:** Xanthine oxidase inhibitors like **Allopurinol** or Febuxostat (target serum urate <6 mg/dL) [1]. * **Precipitating Factors:** Alcohol (especially beer), red meat, seafood, and drugs like **Thiazide diuretics** and Aspirin [2].
Question 254: Aortic arch syndrome is also known as:
- A. Takayasu's arteritis (Correct Answer)
- B. Kawasaki disease
- C. Churg-Strauss syndrome
- D. Giant cell arteritis
Explanation: **Explanation:** **Takayasu’s Arteritis (Option A)** is the correct answer. It is a chronic, systemic inflammatory large-vessel vasculitis that primarily affects the **aorta and its major branches** [1]. The inflammation leads to stenosis, occlusion, or aneurysmal dilation of the vessels. Because it frequently involves the aortic arch and its branches (brachiocephalic, carotid, and subclavian arteries), it results in diminished or absent pulses in the upper extremities, earning it the clinical name **"Aortic Arch Syndrome"** or **"Pulseless Disease."** **Why the other options are incorrect:** * **Kawasaki Disease (Option B):** A medium-vessel vasculitis primarily affecting children [2]. Its most dreaded complication is **coronary artery aneurysms**, not aortic arch syndrome [2]. * **Churg-Strauss Syndrome (Option C):** Now known as Eosinophilic Granulomatosis with Polyangiitis (EGPA), this is a small-vessel vasculitis characterized by asthma, eosinophilia, and necrotizing vasculitis. * **Giant Cell Arteritis (Option D):** While also a large-vessel vasculitis, it typically involves the **extracranial branches of the carotid artery** (e.g., temporal artery) in patients over 50. While it can involve the aorta, it is not synonymous with Aortic Arch Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in young females (<40 years), particularly of Asian descent. * **Clinical Features:** Limb claudication, asymmetric blood pressure (>10 mmHg difference between arms), and bruits over the subclavian or aorta. * **Diagnosis:** Gold standard is **CT/MR Angiography** showing "skip lesions" or wall thickening. * **Histopathology:** Granulomatous inflammation of the adventitia and media [1].
Question 255: Which of the following conditions typically spares the joints of the hand?
- A. Ankylosing Spondylitis (Correct Answer)
- B. Rheumatoid Arthritis
- C. Osteoarthritis
- D. Psoriatic Arthritis
Explanation: ### Explanation **1. Why Ankylosing Spondylitis (AS) is the Correct Answer:** Ankylosing Spondylitis is the prototype of **Seronegative Spondyloarthritides (SpA)**. Its hallmark is involvement of the **axial skeleton**, specifically the sacroiliacy joints (sacroiliitis) and the spine [1]. While AS can involve peripheral joints, it typically affects **large proximal joints** (like the hips and shoulders) in an asymmetrical fashion. It characteristically **spares the small joints of the hands**. If a patient with SpA presents with hand involvement, clinicians should look toward Psoriatic Arthritis or Reactive Arthritis instead. **2. Why the Other Options are Incorrect:** * **Rheumatoid Arthritis (RA):** Classically involves the small joints of the hand, specifically the **MCP and PIP joints**, in a symmetrical pattern [3]. It characteristically spares the DIP joints. * **Osteoarthritis (OA):** Frequently involves the hands, specifically the **DIP joints (Heberden’s nodes)** and **PIP joints (Bouchard’s nodes)**, as well as the first carpometacarpal (CMC) joint [3]. * **Psoriatic Arthritis (PsA):** A Seronegative SpA that, unlike AS, frequently involves the hands. It is known for **DIP joint involvement**, "pencil-in-cup" deformities, and dactylitis ("sausage digits") [2]. **3. NEET-PG High-Yield Pearls:** * **DIP Involvement:** Seen in Psoriatic Arthritis and Osteoarthritis; **spared** in Rheumatoid Arthritis. * **MCP/PIP Involvement:** Classic for Rheumatoid Arthritis. * **HLA-B27:** Strongly associated with AS (>90% of cases) [1]. * **Bamboo Spine:** The classic radiographic finding in late-stage AS due to marginal syndesmophytes and fusion of vertebrae [1]. * **Extra-articular manifestation of AS:** The most common is **Acute Anterior Uveitis** (unilateral) [1].
Question 256: Bridge therapy is employed in which of the following conditions?
- A. Mononeuritis multiplex
- B. Rheumatoid arthritis (Correct Answer)
- C. Osteoarthritis
- D. Caplan syndrome
Explanation: **Explanation:** **Bridge Therapy** refers to the temporary use of fast-acting medications (typically **Corticosteroids**) to control symptoms and inflammation while waiting for slow-acting **Disease-Modifying Anti-Rheumatic Drugs (DMARDs)** to reach therapeutic levels [1]. 1. **Why Rheumatoid Arthritis (RA) is correct:** DMARDs like Methotrexate or Sulfasalazine are the gold standard for RA but take **6 to 12 weeks** to show clinical efficacy [1]. During this "lag period," low-dose Glucocorticoids are used as "bridge therapy" to provide rapid symptomatic relief, reduce joint swelling, and prevent structural damage [1]. Once the DMARDs become effective, the steroids are gradually tapered and discontinued to avoid long-term side effects. 2. **Analysis of Incorrect Options:** * **Mononeuritis multiplex:** This is a clinical pattern of peripheral neuropathy (often seen in vasculitis). While steroids are used, the specific concept of "bridging" to a slow-acting agent is not the standard terminology used here; it usually requires immediate intensive immunosuppression. * **Osteoarthritis:** This is a degenerative joint disease, not a systemic inflammatory condition. Treatment focuses on analgesics, lifestyle modification, and intra-articular injections; DMARDs and systemic steroids are not indicated. * **Caplan syndrome:** This is a combination of RA and pneumoconiosis (lung nodules). While it involves RA, the term "bridge therapy" specifically describes the pharmacological strategy for managing early or flaring RA, rather than the syndrome itself. **High-Yield Clinical Pearls for NEET-PG:** * **Anchor Drug in RA:** Methotrexate is the first-line DMARD [1]. * **Steroid Sparing:** The ultimate goal of bridge therapy is to achieve a "steroid-sparing" effect by transitioning the patient to DMARD maintenance. * **Window of Opportunity:** Early initiation of DMARDs (within 3–6 months) is crucial to prevent irreversible joint erosions [1].
Question 257: Which of the following conditions is associated with anti-proteinase-3 positivity?
- A. Churg Strauss syndrome
- B. Microscopic polyangiitis
- C. Wegener's granulomatosis (Correct Answer)
- D. Polyarteritis nodosa
Explanation: The correct answer is **Wegener’s Granulomatosis** (now officially known as Granulomatosis with Polyangiitis or GPA). **1. Why Wegener’s Granulomatosis is correct:** GPA is a small-vessel vasculitis characterized by the triad of upper respiratory tract involvement, lower respiratory tract involvement, and glomerulonephritis [2]. The hallmark serological marker for GPA is **c-ANCA** (cytoplasmic Antineutrophil Cytoplasmic Antibody), which shows a diffuse cytoplasmic staining pattern on immunofluorescence. The primary target antigen for c-ANCA is **Proteinase-3 (PR3)**. Approximately 90% of patients with active, systemic GPA are positive for anti-PR3 antibodies. **2. Why the other options are incorrect:** * **Churg-Strauss Syndrome (EGPA):** This is primarily associated with **p-ANCA** (perinuclear pattern), where the target antigen is **Myeloperoxidase (MPO)** [1]. It is clinically distinguished by asthma and peripheral eosinophilia [1], [2]. * **Microscopic Polyangiitis (MPA):** While MPA is also a small-vessel vasculitis, it is most strongly associated with **p-ANCA (anti-MPO)** rather than anti-PR3. Unlike GPA, it lacks granulomatous inflammation [2]. * **Polyarteritis Nodosa (PAN):** PAN is a medium-vessel vasculitis that is characteristically **ANCA-negative**. It is frequently associated with Hepatitis B infection and involves "rosary sign" microaneurysms on angiography [2]. **High-Yield Clinical Pearls for NEET-PG:** * **c-ANCA = Anti-PR3** (Associated with GPA/Wegener’s). * **p-ANCA = Anti-MPO** (Associated with MPA, EGPA, and Primary Sclerosing Cholangitis). * **GPA Triad:** Sinusitis (saddle nose deformity), Lung nodules/hemoptysis, and Crescentic Glomerulonephritis [2]. * **Drug-induced ANCA:** Propylthiouracil (PTU), Hydralazine, and Methimazole can cause p-ANCA positivity.
Question 258: All of the following are true about Temporal Arteritis except?
- A. Polymyalgia Rheumatica
- B. Anemia
- C. Low ESR (Correct Answer)
- D. Sudden blindness
Explanation: Temporal Arteritis, also known as **Giant Cell Arteritis (GCA)**, is a large-vessel vasculitis that primarily affects the extracranial branches of the carotid artery [1]. **Why "Low ESR" is the correct answer:** In GCA, the Erythrocyte Sedimentation Rate (ESR) is characteristically **markedly elevated**, often exceeding **100 mm/hr**. A low or normal ESR is extremely rare in active disease and is used as a negative predictive factor [1]. C-reactive protein (CRP) is also typically elevated. **Analysis of other options:** * **Polymyalgia Rheumatica (PMR):** Approximately 40–50% of patients with GCA also have PMR, characterized by proximal muscle pain and stiffness (shoulders and hips) [1]. * **Anemia:** Chronic inflammation in GCA leads to **Anemia of Chronic Disease** (normocytic, normochromic), which is a common systemic finding. * **Sudden Blindness:** This is the most feared complication. It occurs due to **Anterior Ischemic Optic Neuropathy (AION)** caused by occlusion of the posterior ciliary arteries [1]. It is a medical emergency requiring immediate high-dose steroids. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Temporal artery biopsy (look for "skip lesions"; hence, a long segment must be biopsied) [1]. * **Histopathology:** Granulomatous inflammation with multinucleated giant cells and fragmentation of the internal elastic lamina [1]. * **Treatment:** Do not wait for biopsy results; start **High-dose Glucocorticoids** immediately if GCA is suspected to prevent permanent vision loss [1]. * **Demographics:** Almost exclusively occurs in patients **>50 years** of age.
Question 259: A 27-year-old male presents with burning micturition and urethral discharge. After 4 weeks, he develops joint pains involving both knees and ankles, redness of the eyes, and skin lesions. What is the most probable clinical diagnosis?
- A. Psoriasis vulgaris
- B. Reiter's syndrome (Correct Answer)
- C. Behcet's syndrome
- D. Sarcoidosis
Explanation: ### **Explanation** The clinical presentation describes the classic triad of **Reiter’s Syndrome** (a subtype of **Reactive Arthritis**): **Urethritis** (burning micturition/discharge), **Arthritis** (asymmetric involvement of large weight-bearing joints like knees and ankles), and **Conjunctivitis** (redness of eyes) [1]. **1. Why Reiter’s Syndrome is Correct:** Reactive arthritis is an immune-mediated spondyloarthropathy that typically follows a gastrointestinal (e.g., *Salmonella, Shigella*) or urogenital infection (most commonly ***Chlamydia trachomatis***) [1]. The symptoms usually manifest 1–4 weeks after the inciting infection. The presence of skin lesions (likely *Keratoderma blennorrhagicum* or *Circinate balanitis*) further supports this diagnosis [1]. **2. Why Other Options are Incorrect:** * **Psoriasis Vulgaris:** While it causes skin lesions and arthritis (Psoriatic Arthritis), it is not typically preceded by urethritis or conjunctivitis. Psoriatic plaques are usually chronic and found on extensor surfaces. X-ray findings like asymmetrical syndesmophytes can distinguish Reiter's from other spondyloarthropathies [3]. * **Behcet’s Syndrome:** Characterized by the triad of oral ulcers, genital ulcers, and uveitis. While it involves skin and joints, the absence of preceding urethritis and the specific distribution of ulcers make it less likely. * **Sarcoidosis:** Typically presents with bilateral hilar lymphadenopathy, cough, and erythema nodosum. While it can cause uveitis and arthritis (Lofgren’s syndrome), it does not present with urethral discharge. **Clinical Pearls for NEET-PG:** * **Mnemonic:** "Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)." * **HLA Association:** Strongly associated with **HLA-B27** (60–80% of cases) [2]. * **Skin Findings:** *Keratoderma blennorrhagicum* (hyperkeratotic lesions on palms/soles) is pathognomonic and histologically indistinguishable from pustular psoriasis [1]. * **Treatment:** NSAIDs are first-line; antibiotics are used to treat the underlying *Chlamydia* infection but do not always resolve the arthritis.
Question 260: Which of the following statements is not true about Gout?
- A. Alcohol is a risk factor for the disease.
- B. Tophi are characteristic of gout.
- C. The great toe is most commonly affected.
- D. Aspiration shows urate crystals which are needle-shaped and positively birefringent. (Correct Answer)
Explanation: The correct answer is **D** because it contains a factual error regarding the optical properties of Monosodium Urate (MSU) crystals. ### 1. Why Option D is the Correct Answer (The False Statement) In Gout, synovial fluid aspiration reveals MSU crystals that are indeed **needle-shaped**, but they are **strongly negatively birefringent** under polarized light microscopy. * **Negative birefringence** means the crystals appear **yellow** when aligned parallel to the slow axis of the compensator and blue when perpendicular. * **Positive birefringence** is characteristic of **Calcium Pyrophosphate Deposition Disease (CPPD/Pseudogout)**, where crystals are rhomboid-shaped and appear blue when parallel to the axis. ### 2. Analysis of Other Options (True Statements) * **Option A:** Alcohol (especially beer) is a major risk factor. It increases urate production (via ATP degradation) and decreases renal excretion (by increasing lactic acid, which competes with uric acid for excretion). * **Option B:** Tophi are pathognomonic of chronic tophaceous gout. They are collections of MSU crystals surrounded by granulomatous inflammation, often found in the olecranon bursa, Achilles tendon, or ear helix. * **Option C:** The first metatarsophalangeal (MTP) joint is the most common site for the initial attack, a clinical presentation known as **Podagra**. ### 3. High-Yield Clinical Pearls for NEET-PG * **Gold Standard Diagnosis:** Polarized light microscopy of synovial fluid. * **Radiology:** Look for "punched-out" erosions with overhanging edges (**Martel’s sign**). * **Management:** * *Acute attack:* NSAIDs (first-line), Colchicine, or Steroids. * *Chronic/Prophylaxis:* Allopurinol (Xanthine oxidase inhibitor) is first-line. * **Dietary Triggers:** High-purine foods (red meat, seafood) and high-fructose corn syrup.
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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