Rheumatology and Immunology Practice Questions

Q: A 23-year-old man presents with new low back pain, stiffness, and left eye discomfort. He notes increased sensitivity to sunlight. The back pain is worse at night, described as a dull ache in the back and buttock area. Physical examination reveals paravertebral muscle, iliac crest, and ischial tuberosity tenderness with limited lumbar spine flexion. His eye is inflamed with a constricted pupil. Pelvic x-rays show sacroiliitis. What is the most likely diagnosis for his eye symptoms, considering it is the most common extra-articular manifestation of this condition?

Acute anterior uveitis. The clinical presentation describes a classic case of **Ankylosing Spondylitis (AS)**, a seronegative spondyloarthropathy [1]. The patient exhibits inflammatory back pain (worse at night/rest, stiffness), enthesitis (tenderness at iliac crest/ischial tuberosity), and radiographic sacroiliitis [2]. ### 1. Why Acute Anterior Uveitis is Correct **Acute Anterior Uveitis (AAU)**, also known as iridocyclitis, is the **most common extra-articular manifestation** of Ankylosing Spondylitis, occurring in 25–40% of patients [1]. It typically presents as sudden-onset unilateral eye pain, redness, photophobia (sensitivity to light), and blurred vision. The finding of a **constricted pupil** (due to ciliary spasm) is a hallmark sign that differentiates it from other causes of red eye. ### 2. Why Incorrect Options are Wrong * **Glaucoma:** While secondary glaucoma can be a *complication* of chronic uveitis, it is not the primary manifestation. Acute angle-closure glaucoma presents with a mid-dilated pupil, not a constricted one. * **Keratitis:** This involves corneal inflammation. While it causes photophobia, it is not specifically associated with AS and usually presents with corneal opacities or ulcers. * **Conjunctivitis:** This is a common cause of red eye but is typically painless, lacks photophobia, and does not affect the pupil size or cause deep-seated ache. ### 3. NEET-PG High-Yield Pearls * **HLA-B27:** Strongly associated with AS (>90% of cases) [1]. * **Schober’s Test:** Used to quantify limited lumbar spine flexion. * **Bamboo Spine:** A late radiographic feature due to syndesmophyte formation [2]. * **Treatment of AAU:** Urgent referral to ophthalmology; managed with topical corticosteroids and cycloplegic agents to prevent synechiae. * **Other Extra-articular features:** Aortitis (Aortic regurgitation), Apical lung fibrosis, and IgA nephropathy.

Q: What is true about Henoch-Schonlein purpura?

All of the above. Henoch-Schönlein Purpura (HSP), now formally known as **IgA Vasculitis**, is a small-vessel vasculitis characterized by the deposition of IgA-dominant immune complexes [1]. It typically presents with a classic tetrad of symptoms: palpable purpura, arthralgia, abdominal pain, and renal involvement (hematuria) [1]. * **Option A (Palpable Purpura):** This is the hallmark clinical sign. Unlike thrombocytopenic purpura, the rash in HSP is raised (palpable) because it is caused by inflammatory exudation and vessel wall damage (leukocytoclastic vasculitis), not just simple bleeding. It is most commonly found on the lower extremities and buttocks. * **Option B (Common in children):** HSP is the most common vasculitis in the pediatric population, usually affecting children between the ages of 3 and 15. It often follows an upper respiratory tract infection (URI) [1]. * **Option C (Thrombocytosis):** HSP is a **non-thrombocytopenic** purpura. In fact, because it is an inflammatory condition, the platelet count is typically normal or elevated (reactive thrombocytosis). This is a crucial diagnostic differentiator from Immune Thrombocytopenic Purpura (ITP), where the platelet count is low. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Primarily clinical. Skin biopsy shows **Leukocytoclastic Vasculitis** with **IgA deposition** on immunofluorescence. * **Renal Involvement:** HSP nephritis is histologically identical to **IgA Nephropathy (Berger’s disease)** [2], [3]. * **GI Complication:** In children, HSP is a known lead point for **intussusception** (usually ileo-ileal). * **Treatment:** Mostly supportive; steroids are used for severe GI symptoms or renal involvement but do not prevent chronic kidney disease.

Q: Which of the following are examples of seronegative arthritis?

All of the above. The term **Seronegative Spondyloarthropathies (SpA)** refers to a group of multi-system inflammatory disorders that share common clinical, pathological, and genetic features. The hallmark of these conditions is the **absence of Rheumatoid Factor (RF)** and Anti-CCP antibodies in the serum, hence the term "seronegative." **Why "All of the above" is correct:** The classic members of this group are remembered by the mnemonic **PEAR**: * **P – Psoriatic Arthritis:** Associated with skin psoriasis and nail changes (pitting). [1] * **E – Enteropathic Arthritis:** Associated with Inflammatory Bowel Disease (Ulcerative Colitis and Crohn’s). * **A – Ankylosing Spondylitis (AS):** The prototype of the group, primarily affecting the sacroiliac joints and spine. [1] * **R – Reactive Arthritis (formerly Reiter’s Syndrome):** Arthritis that develops following a urogenital (Chlamydia) or gastrointestinal (Shigella, Salmonella) infection. [1] **Common Features of Seronegative SpA:** 1. **Genetic Association:** Strong link with **HLA-B27**. [1] 2. **Pathology:** The primary site of inflammation is the **Enthesis** (where tendons/ligaments insert into bone), unlike Rheumatoid Arthritis which is primarily a synovitis. [1] 3. **Clinical:** Asymmetrical peripheral arthritis, sacroiliitis, uveitis, and "bamboo spine" (in AS). [1] **High-Yield Clinical Pearls for NEET-PG:** * **Most common extra-articular manifestation:** Acute Anterior Uveitis. [1] * **Schober’s Test:** Used to assess reduced lumbar spine mobility in Ankylosing Spondylitis. * **Radiology:** Look for "Dactylitis" (sausage digits) in Psoriatic and Reactive arthritis, and "Syndesmophytes" in AS. [1] * **Reactive Arthritis Triad:** Urethritis, Conjunctivitis, and Arthritis ("Can't see, can't pee, can't climb a tree"). [1]

Q: Intravenous immunoglobulin is indicated in all of the following conditions except?

Wegener's granulomatosis. The correct answer is **Wegener's granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA). **1. Why Wegener's Granulomatosis is the correct answer:** GPA is a small-vessel vasculitis associated with c-ANCA. The mainstay of treatment for induction of remission involves **Corticosteroids** combined with either **Cyclophosphamide** or **Rituximab**. While IVIG has been studied as an adjunctive therapy in refractory cases, it is *not* a standard or first-line indication for the disease. **2. Analysis of Incorrect Options:** * **Kawasaki Disease:** IVIG is the **gold standard** treatment. When administered within the first 10 days of fever, it significantly reduces the risk of coronary artery aneurysms. * **Acute ITP:** IVIG is indicated when a rapid rise in platelet count is required (e.g., life-threatening bleed or pre-surgery). It works by saturating the Fc receptors on splenic macrophages, preventing platelet destruction. * **Myasthenic Crisis:** IVIG and Plasmapheresis are the first-line treatments for rapid stabilization during a crisis or prior to thymectomy, as they quickly lower the levels of pathogenic acetylcholine receptor antibodies [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of IVIG:** It provides passive immunity, neutralizes autoantibodies, and modulates Fc receptor expression. * **Other common indications:** Guillain-Barré Syndrome (GBS), Dermatomyositis (refractory), and Common Variable Immunodeficiency (CVID). * **Side Effect:** A high-yield complication to remember for exams is **Aseptic Meningitis** and acute renal failure (due to sucrose stabilizers). * **Contraindication:** IVIG is contraindicated in patients with **IgA deficiency** due to the risk of anaphylaxis.

Q: What is the most specific symptom of temporal arteritis?

Jaw claudication. **Explanation:** **Temporal Arteritis (Giant Cell Arteritis)** is a large-vessel vasculitis that primarily affects the branches of the external carotid artery. **Why Jaw Claudication is the correct answer:** While headache is the most common symptom, **jaw claudication** (pain in the jaw muscles during chewing that resolves with rest) is the **most specific symptom** (specificity >90%). It occurs due to ischemia of the masseter and temporalis muscles resulting from vasculitis of the maxillary artery and its branches. Its presence significantly increases the likelihood of the diagnosis. **Analysis of Incorrect Options:** * **A. Visual Loss:** This is the most dreaded complication (due to anterior ischemic optic neuropathy), but it is not the most specific. It occurs in about 15-20% of untreated patients [1]. * **C. Temporal Headache:** This is the **most common** presenting symptom (occurring in ~75% of cases) [1]. However, because headaches are ubiquitous in clinical practice, it lacks the specificity of jaw claudication [2]. * **D. Polymyalgia Rheumatica (PMR):** PMR (proximal muscle pain and stiffness) is associated with Temporal Arteritis in about 40-50% of cases [1], but it is a distinct clinical syndrome rather than a specific symptom of the arteritis itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Temporal artery biopsy (look for "skip lesions") [1]. * **Best Initial Test:** ESR (usually >50 mm/hr, often >100 mm/hr) and CRP [1]. * **Treatment:** Immediate high-dose corticosteroids (Prednisone) to prevent permanent blindness [1]. Do not wait for biopsy results to start treatment. * **Demographics:** Almost exclusively occurs in patients >50 years of age.

Q: Which HLA antigen is associated with rheumatoid arthritis?

HLA DR4. **Explanation:** The correct answer is **HLA DR4**. **1. Why HLA DR4 is correct:** Rheumatoid Arthritis (RA) is strongly associated with the **HLA-DRB1** gene, specifically the alleles that encode a specific sequence of amino acids (70-74) known as the **"Shared Epitope."** The most common serotype associated with this genetic predisposition is **HLA DR4** (specifically DRB1*0401 and *0404). This shared epitope is thought to influence the presentation of arthritogenic antigens to T-cells, triggering the autoimmune inflammatory cascade characteristic of RA. Patients with HLA DR4 often have more severe, erosive disease. **2. Why the other options are incorrect:** * **HLA DR3:** This is primarily associated with **Systemic Lupus Erythematosus (SLE)**, Sjogren’s syndrome, and Type 1 Diabetes Mellitus. * **HLA DR27:** This is not a standard HLA nomenclature; it is likely a distractor combining DR and B27. * **HLA B27:** This is a Class I MHC molecule strongly associated with **Seronegative Spondyloarthropathies**, such as Ankylosing Spondylitis (90% association), Reactive Arthritis, and Psoriatic Arthritis [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **HLA DR4:** Associated with Rheumatoid Arthritis and Pemphigus Vulgaris. * **HLA DR2:** Associated with Multiple Sclerosis and Goodpasture Syndrome. * **HLA DR3 & DR4:** Both are associated with Type 1 Diabetes Mellitus. * **HLA B51:** Associated with Behcet’s Disease. * **Felty’s Syndrome:** A severe form of RA (triad of RA, splenomegaly, and neutropenia) is very strongly linked to HLA DR4.

Question 1

A 23-year-old man presents with new low back pain, stiffness, and left eye discomfort. He notes increased sensitivity to sunlight. The back pain is worse at night, described as a dull ache in the back and buttock area. Physical examination reveals paravertebral muscle, iliac crest, and ischial tuberosity tenderness with limited lumbar spine flexion. His eye is inflamed with a constricted pupil. Pelvic x-rays show sacroiliitis. What is the most likely diagnosis for his eye symptoms, considering it is the most common extra-articular manifestation of this condition?

Accepted Answer

Acute anterior uveitis

Answer

Glaucoma

Answer

Keratitis

Answer

Conjunctivitis

Question 2

Which of the following statements is false regarding Rheumatoid Arthritis?

Accepted Answer

Ligament fibrosis is common early in the disease

Answer

Often associated with hypertrophy of the synovial membrane

Answer

Rheumatoid nodules are typically painless

Answer

The disorder can cause permanent deformity

Question 3

What is true about Henoch-Schonlein purpura?

Accepted Answer

All of the above

Answer

Palpable purpura

Answer

Common in children

Answer

Thrombocytosis

Question 4

Which of the following are examples of seronegative arthritis?

Accepted Answer

All of the above

Answer

Ankylosing spondylitis

Answer

Reiter's arthritis

Answer

Psoriatic arthritis

Question 5

Intravenous immunoglobulin is indicated in all of the following conditions except?

Accepted Answer

Wegener's granulomatosis

Answer

Kawasaki disease

Answer

Acute immune thrombocytopenic purpura (ITP)

Answer

Myasthenic crisis

Question 6

What is the most specific symptom of temporal arteritis?

Accepted Answer

Jaw claudication

Answer

Visual loss

Answer

Temporal headache

Answer

Polymyalgia rheumatica

Question 7

A 50-year-old man presents with fatigue and painful swelling of both hands. He experiences significant morning stiffness. Physical examination reveals symmetric erythema, swelling, and tenderness of the proximal interphalangeal and metacarpophalangeal joints. Plain hand x-rays are ordered. Which of the following x-ray findings is characteristic of this condition?

Accepted Answer

Loss of articular cartilage and bone erosion

Answer

Normal

Answer

Osteolytic changes

Answer

Osteosclerotic changes

Question 8

Which one of the following statements is best suited for isolated polymyalgia rheumatica?

Accepted Answer

Response to oral corticosteroids typically occurs within seven days.

Answer

Temporal artery biopsy is necessary to confirm the diagnosis.

Answer

Corticosteroid therapy should be withdrawn after six months.

Answer

Sudden uniocular blindness suggests steroid-induced cataract.

Question 9

Which HLA antigen is associated with rheumatoid arthritis?

Accepted Answer

HLA DR4

Answer

HLADR3

Answer

HLA DR27

Answer

HLA B27

Question 10

A 30-year-old male presented with pain and swelling of the right knee and ankle joints, particularly at the insertion sites, along with burning sensation and pain during micturition, urethral discharge, and fever for two weeks. The patient also reported multiple episodes of bloody diarrhea one week prior. On examination, bilateral conjunctivitis, oral ulcers, plantar fasciitis, onycholysis, and distal yellow discoloration of nails were noted. X-ray of the pelvis with bilateral hips was normal. Lab findings revealed raised ESR and other acute phase reactants, mild anemia, and increased HLA-B27 titers. Joint aspirate was sterile. What is the most likely diagnosis?

Accepted Answer

Reactive arthritis

Answer

Septic arthritis

Answer

Psoriatic arthritis

Answer

Ankylosing Spondylitis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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