Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 281: A 45-year-old male has rhinitis, bronchial asthma, eosinophilia, and systemic vasculitis. What is the probable diagnosis?

A. Goodpasture syndrome
B. Cryptogenic fibrosing alveolitis
C. Churg-Strauss syndrome (Correct Answer)
D. Sarcoidosis

Explanation: ### Explanation The clinical triad of **bronchial asthma, peripheral eosinophilia, and systemic vasculitis** is the hallmark of **Churg-Strauss Syndrome**, now officially known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**. #### Why Churg-Strauss Syndrome is Correct: EGPA is a small-to-medium vessel necrotizing vasculitis. The diagnosis is based on the American College of Rheumatology (ACR) criteria, which include: 1. **Asthma** (often the first manifestation). 2. **Eosinophilia** (>10% of total WBC count). 3. **Paranasal sinus abnormalities** (rhinitis/sinusitis). 4. **Neuropathy** (commonly Mononeuritis Multiplex). 5. **Migratory pulmonary opacities**. 6. **Extravascular eosinophils** on biopsy. #### Why Other Options are Incorrect: * **Goodpasture Syndrome:** Characterized by anti-GBM antibodies causing a pulmonary-renal syndrome (alveolar hemorrhage and glomerulonephritis). It does not present with asthma or eosinophilia. * **Cryptogenic Fibrosing Alveolitis (IPF):** A chronic, progressive fibrosing interstitial pneumonia. It presents with dry cough and exertional dyspnea, not systemic vasculitis or eosinophilia. * **Sarcoidosis:** A multi-system granulomatous disease characterized by non-caseating granulomas and bilateral hilar lymphadenopathy. While it affects the lungs, it is not associated with asthma or significant peripheral eosinophilia. #### NEET-PG High-Yield Pearls: * **Serology:** p-ANCA (anti-MPO) is positive in approximately 40–50% of EGPA cases. * **Cardiac Involvement:** This is the leading cause of mortality in EGPA (e.g., eosinophilic myocarditis). * **Phases:** EGPA typically progresses through three phases: Prodromal (allergic rhinitis/asthma) → Eosinophilic (tissue infiltration) → Vasculitic phase. * **Treatment:** Corticosteroids are the mainstay; Cyclophosphamide is added for severe organ involvement.

Question 282: All of the following are included in the criteria for diagnosis of Systemic Lupus Erythematosus, except:

A. Oral ulcers
B. Psychosis
C. Discoid rash
D. Leucocytosis (Correct Answer)

Explanation: The diagnosis of **Systemic Lupus Erythematosus (SLE)** is primarily based on the **ACR (American College of Rheumatology)** or the **SLICC (Systemic Lupus International Collaborating Clinics)** criteria [2]. ### **Why Leucocytosis is the Correct Answer** In SLE, the hematological hallmark is **cytopenia** (a decrease in cell counts) rather than leucocytosis (an increase). The diagnostic criteria specifically include **Leukopenia** (<4,000/mm³), **Lymphopenia** (<1,500/mm³), or **Thrombocytopenia** (<100,000/mm³) [2]. Leucocytosis is typically seen in infections or as a side effect of corticosteroid therapy, but it is not a diagnostic feature of the disease itself. ### **Analysis of Other Options** * **Oral Ulcers (Option A):** These are a classic clinical criterion. They are typically **painless** and occur on the hard palate or nasopharynx. * **Psychosis (Option B):** This falls under the **Neurologic criteria**. Other manifestations include seizures, in the absence of metabolic uremia or offending drugs. * **Discoid Rash (Option C):** This is one of the four dermatological criteria (alongside Malar rash, Photosensitivity, and Oral ulcers) [1]. It is characterized by erythematous raised patches with adherent keratotic scaling and follicular plugging [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **Most Common Hematological Abnormality:** Anemia of chronic disease. * **Most Specific Hematological Criterion:** Autoimmune hemolytic anemia with reticulocytosis [2]. * **Most Specific Antibody:** Anti-dsDNA and Anti-Smith (Anti-Sm) [2][3]. * **Best Screening Test:** ANA (High sensitivity, low specificity) [2][3]. * **Drug-Induced Lupus:** Characterized by **Anti-Histone antibodies**; notably spares the kidneys and CNS. * **Complement Levels:** C3 and C4 levels are typically **decreased** during active flares (especially Lupus Nephritis) [2].

Question 283: Which of the following conditions is characterized by the pathognomonic lesion 'tophus'?

A. Multiple myeloma
B. Cystinosis
C. Gout (Correct Answer)
D. Eales disease

Explanation: Gout (Correct Answer): Gout is a metabolic disorder characterized by hyperuricemia and the deposition of Monosodium Urate (MSU) crystals in joints and soft tissues [1]. The tophus is the pathognomonic chronic lesion of gout [3]. It consists of a large collection of MSU crystals surrounded by an intense inflammatory granulomatous reaction (macrophages, lymphocytes, and multinucleated giant cells) [1]. Tophi typically appear in the helix of the ear, olecranon bursa, and Achilles tendon [1]. Under polarized microscopy, these crystals show strong negative birefringence and are needle-shaped. Analysis of Incorrect Options: * Multiple Myeloma: This is a plasma cell dyscrasia characterized by "punched-out" lytic bone lesions and Bence-Jones proteins. While it can cause hyperuricemia due to high cell turnover, it does not form tophi [2]. * Cystinosis: A lysosomal storage disorder leading to the accumulation of cystine crystals in various organs (kidneys, eyes). It presents with Fanconi syndrome but not urate tophi. * Eales Disease: An idiopathic inflammatory peripheral retinal perivasculitis. It is an ophthalmological condition and has no association with crystal deposition or tophi. NEET-PG High-Yield Pearls: * Gold Standard Diagnosis: Identification of needle-shaped, negatively birefringent crystals from joint aspirate. * Radiology: Chronic gout shows characteristic "punched-out" erosions with overhanging edges (Martel’s sign). * Drug of Choice: NSAIDs or Colchicine for acute attacks; Allopurinol (Xanthine oxidase inhibitor) for chronic management [4]. * Precipitating factors: Alcohol, red meat, and drugs like Thiazides and Loop diuretics [2].

Question 284: Autoimmune destruction of platelets is seen in which of the following conditions?

A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
B. Rheumatoid Arthritis
C. Reiter's Disease
D. Polyarteritis Nodosa

Explanation: ### Explanation **1. Why SLE is the Correct Answer:** Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease characterized by the production of autoantibodies against various self-antigens [2]. Hematological involvement is a hallmark of SLE (included in both ACR and SLICC criteria). The destruction of platelets in SLE occurs via **Type II Hypersensitivity**, where IgG autoantibodies (anti-platelet antibodies) target surface glycoproteins on platelets [1]. These opsonized platelets are then prematurely cleared by the splenic macrophages, a mechanism identical to **Immune Thrombocytopenic Purpura (ITP)**. In fact, ITP can often be the presenting feature of SLE. Thrombocytopenia and hemolytic anemia are typical markers of active SLE [3]. **2. Why the Other Options are Incorrect:** * **Rheumatoid Arthritis (RA):** While RA is autoimmune, it typically presents with **thrombocytosis** (elevated platelets) as an acute-phase reactant to chronic inflammation. A decrease in platelets in RA is rare and usually secondary to drug toxicity (e.g., Methotrexate) or **Felty’s Syndrome** (where splenomegaly leads to sequestration). * **Reiter’s Disease (Reactive Arthritis):** This is a seronegative spondyloarthropathy triggered by infections (e.g., Chlamydia). It does not involve autoantibody-mediated destruction of blood cells. * **Polyarteritis Nodosa (PAN):** This is a necrotizing vasculitis of medium-sized arteries. While it causes systemic inflammation, it does not typically involve the autoimmune destruction of platelets. **3. High-Yield Clinical Pearls for NEET-PG:** * **Hematological Criteria for SLE:** Leukopenia (<4,000/mm³), Lymphopenia (<1,500/mm³), Hemolytic anemia (Coombs' positive), and Thrombocytopenia (<100,000/mm³) [3]. * **Evans Syndrome:** The simultaneous or sequential occurrence of Immune Thrombocytopenia (ITP) and Autoimmune Hemolytic Anemia (AIHA); frequently associated with SLE. * **Most Common Hematological Abnormality in SLE:** Anemia of Chronic Disease (though Lymphopenia is more specific).

Question 285: Recurrent aspiration pneumonia is most commonly caused by which of the following conditions?

A. Dermatomyositis/polymyositis
B. Rheumatoid arthritis
C. Progressive systemic sclerosis (Correct Answer)
D. Systemic lupus erythematosus

Explanation: The correct answer is **Progressive Systemic Sclerosis (Scleroderma)**. [1] **Why it is correct:** Systemic Sclerosis (SSc) involves extensive fibrosis and smooth muscle atrophy of the gastrointestinal tract, most notably the **lower two-thirds of the esophagus**. This leads to: 1. **Esophageal Dysmotility:** Loss of peristalsis. 2. **Incompetent Lower Esophageal Sphincter (LES):** Resulting in severe Gastroesophageal Reflux Disease (GERD). [1] The combination of a dilated, aperistaltic esophagus and a weak LES allows gastric contents to reflux easily, especially while supine, leading to **recurrent micro-aspiration** and aspiration pneumonia. This is a major contributor to pulmonary morbidity alongside Interstitial Lung Disease (ILD). [1] **Why the other options are incorrect:** * **Dermatomyositis/Polymyositis:** While these can cause dysphagia, they primarily affect the **striated muscle** of the upper third of the esophagus (pharyngeal weakness). While aspiration can occur, it is less frequent as a chronic, recurrent feature compared to the structural reflux seen in SSc. * **Rheumatoid Arthritis:** Pulmonary involvement typically manifests as ILD (UIP pattern) or pleural effusions, not recurrent aspiration. * **Systemic Lupus Erythematosus:** Lung involvement usually presents as pleuritis, "shrinking lung syndrome," [2] or acute lupus pneumonitis, rather than aspiration-related pathology. **High-Yield Clinical Pearls for NEET-PG:** * **CREST Syndrome:** Calcinosis, Raynaud’s, **Esophageal dysmotility**, Sclerodactyly, Telangiectasia. [1] * **Barium Swallow in SSc:** Shows a "glass pipe" appearance (dilated, rigid esophagus). * **Manometry:** Shows low LES pressure and absent distal peristalsis. * **Most common cause of death in SSc:** Now Interstitial Lung Disease (formerly Renal Crisis).

Question 286: Which of the following statements is true regarding Rheumatoid arthritis?

A. Typically involves small and large joints symmetrically but spares the cervical spine.
B. Causes pleural effusion with low sugar. (Correct Answer)
C. Pulmonary nodules are absent.
D. Enthesopathy is prominent.

Explanation: ### Explanation **Correct Option: B. Causes pleural effusion with low sugar.** Rheumatoid Arthritis (RA) is a systemic inflammatory disease that can involve extra-articular sites, including the pleura. Rheumatoid pleural effusion is characteristically **exudative** and is hallmarked by **very low glucose levels** (often <30 mg/dL). This occurs due to a combination of increased glucose consumption by inflammatory cells and a selective defect in glucose transport across the inflamed pleura. **Analysis of Incorrect Options:** * **Option A:** While RA typically involves small and large joints symmetrically [1], it **does not spare the cervical spine**. In fact, the cervical spine (specifically the atlanto-axial joint) is the only part of the spine commonly involved in RA, potentially leading to atlanto-axial subluxation [1]. * **Option C:** Pulmonary nodules (Rheumatoid nodules) are a well-recognized extra-articular manifestation of RA [1]. When these nodules occur in the lungs of patients with concomitant coal worker's pneumoconiosis, it is known as **Caplan Syndrome**. * **Option D:** Enthesopathy (inflammation at the site where tendons/ligaments attach to bone) is the hallmark of **Seronegative Spondyloarthropathies** (like Ankylosing Spondylitis), not RA. RA primarily targets the **synovium** [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Pleural Fluid in RA:** Low glucose, low complement (C3, C4), and high LDH. * **Most Common Cardiac Manifestation:** Pericarditis (though often asymptomatic). * **Felty’s Syndrome:** Triad of RA, Splenomegaly, and Neutropenia [1]. * **Joint Sparing:** RA characteristically spares the **Distal Interphalangeal (DIP) joints** and the lumbosacral spine [1].

Question 287: A young male patient has a history of diarrhea 3-4 weeks ago, and is now complaining of right knee pain, swelling in other joints with signs of inflammation and dactylitis. What is the most probable causative organism?

A. Shigella (Correct Answer)
B. Campylobacter
C. E coli
D. Yersinia

Explanation: **Explanation:** The clinical presentation of asymmetric oligoarthritis (right knee pain), dactylitis ("sausage digit"), and a preceding gastrointestinal infection (3–4 weeks prior) is a classic description of **Reactive Arthritis (ReA)** [2]. **Why Shigella is the Correct Answer:** Reactive Arthritis is an HLA-B27 associated spondyloarthropathy that occurs following certain enteric or genitourinary infections [1]. Among the enteric pathogens, **Shigella flexneri** is a well-documented trigger [2]. In the context of competitive exams like NEET-PG, when a "young male" presents with post-diarrheal arthritis and dactylitis, Shigella is a high-yield causative organism frequently tested alongside Salmonella and Yersinia. **Analysis of Incorrect Options:** * **Campylobacter:** While *C. jejuni* is a common cause of diarrhea and can trigger ReA, it is more classically associated with **Guillain-Barré Syndrome** [2]. * **E. coli:** Most strains of *E. coli* (including ETEC and EHEC) are **not** typically associated with the development of Reactive Arthritis. * **Yersinia:** *Yersinia enterocolitica* is a potent trigger for ReA (especially in Northern Europe), but in many standardized question banks, Shigella is the preferred answer for a classic "dysenteric" preceding event leading to the full triad or dactylitis [2]. **Clinical Pearls for NEET-PG:** * **The Triad:** "Can't see, can't pee, can't climb a tree" (Urethritis, Conjunctivitis, and Arthritis) [2]. Note: The full triad is present in only 1/3 of patients. * **Dactylitis:** A hallmark sign of spondyloarthropathies (ReA and Psoriatic Arthritis). * **Keratoderma Blennorrhagicum:** Vesicular, crusty skin lesions on palms/soles, pathognomonic for ReA [2]. * **Genetic Link:** Strongly associated with **HLA-B27** (positive in 60-80% of cases) [1].

Question 288: Antineutrophil cytoplasmic antibody-associated vasculitides include all except?

A. Wegener granulomatosis
B. Polyarteritis nodosa (Correct Answer)
C. Microscopic polyangiitis
D. Churg-Strauss syndrome

Explanation: **Explanation:** The ANCA-associated vasculitides (AAV) are a group of systemic necrotizing vasculitides that primarily affect small vessels (capillaries, venules, and arterioles) and are strongly associated with antineutrophil cytoplasmic antibodies [2]. **Why Polyarteritis Nodosa (PAN) is the correct answer:** Polyarteritis nodosa is a **medium-vessel vasculitis**. By definition, classic PAN is **not associated with ANCA**. It typically involves necrotizing inflammation of medium-sized muscular arteries, often leading to microaneurysms (e.g., "rosary sign" on renal angiography). It is frequently associated with **Hepatitis B virus (HBV)** infection rather than ANCA. **Analysis of Incorrect Options:** * **Wegener Granulomatosis (Granulomatosis with Polyangiitis - GPA):** A small-vessel vasculitis characterized by granulomatous inflammation of the respiratory tract and glomerulonephritis. It is strongly associated with **c-ANCA (anti-PR3)**. * **Microscopic Polyangiitis (MPA):** A small-vessel vasculitis similar to GPA but **lacks granulomatous inflammation**. It is most commonly associated with **p-ANCA (anti-MPO)**. * **Churg-Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis - EGPA):** Characterized by asthma, peripheral eosinophilia, and granulomatous inflammation [1]. Approximately 40-50% of patients are positive for **p-ANCA (anti-MPO)** [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **c-ANCA (Cytoplasmic):** Targets Proteinase-3 (PR3); specific for GPA. 2. **p-ANCA (Perinuclear):** Targets Myeloperoxidase (MPO); associated with MPA and EGPA. 3. **Pauci-immune Glomerulonephritis:** A hallmark of AAV where renal biopsy shows necrotizing GN with minimal or no immune deposits. 4. **PAN Rule-out:** If a patient has involvement of the lungs (pulmonary capillaries), it is likely MPA or GPA, not classic PAN, as PAN spares the pulmonary vessels.

Question 289: A previously asymptomatic 62-year-old woman presents with sudden onset of severe midback pain. X-rays reveal an anterior compression fracture of T10. Other vertebral bodies show decreased mineral density and prominent vertical striations. Which of the following is the most likely diagnosis?

A. Multiple myeloma
B. Metastatic breast cancer
C. Vitamin D deficiency
D. Osteoporosis (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Osteoporosis** The clinical presentation of a postmenopausal woman with a sudden-onset vertebral compression fracture and specific radiographic findings is classic for **Osteoporosis**. [1] * **Pathophysiology:** Osteoporosis involves a reduction in total bone mass but with a normal ratio of mineral to osteoid. [1], [2] * **Radiographic Hallmarks:** The "prominent vertical striations" (also known as the **corduroy cloth appearance**) occur because the horizontal trabeculae are resorbed first due to estrogen deficiency/aging, making the remaining vertical stress-bearing trabeculae appear more prominent. Decreased mineral density (osteopenia) and wedge/compression fractures are hallmark complications. [2] **Incorrect Options:** * **A. Multiple Myeloma:** While it causes fractures and osteopenia, it typically presents with systemic symptoms (anemia, renal failure, hypercalcemia) and characteristic "punched-out" lytic lesions rather than vertical striations. * **B. Metastatic Breast Cancer:** Usually presents with focal lytic or blastic lesions and a history of a primary tumor. It does not typically cause generalized vertical striations of the vertebral bodies. * **C. Vitamin D Deficiency (Osteomalacia):** This involves defective mineralization of the osteoid. While it causes low bone density, it is characterized by **Looser’s zones** (pseudofractures) and "fuzzy" trabeculae rather than the sharp vertical striations seen in osteoporosis. [3] **High-Yield Pearls for NEET-PG:** 1. **Gold Standard Diagnosis:** Dual-energy X-ray absorptiometry (DEXA) scan. A **T-score ≤ -2.5** defines osteoporosis. [3] 2. **Most Common Site of Fracture:** Vertebral bodies (often asymptomatic), followed by the hip and distal radius (Colles’ fracture). [2] 3. **Codfish Vertebrae:** A term used when the vertebral endplates bow inward due to disc pressure against weakened bone, often seen in advanced osteoporosis. 4. **First-line Treatment:** Bisphosphonates (e.g., Alendronate). Ensure adequate Calcium and Vitamin D supplementation. [3], [4]

Question 290: Anti-alpha fodrin autoantibodies are seen in which of the following conditions?

A. Polymyositis
B. Crohn's disease
C. Sjogren's syndrome (Correct Answer)
D. Graves' disease

Explanation: **Explanation:** **Sjogren’s Syndrome (SS)** is a chronic autoimmune disorder characterized by lymphocytic infiltration of exocrine glands. While **Anti-Ro (SS-A)** and **Anti-La (SS-B)** are the classic serological markers, **Anti-alpha fodrin antibodies** have emerged as highly specific markers for the condition [1]. Alpha-fodrin is a 240 kDa cytoskeleton protein (organ-specific autoantigen) found in the salivary and lacrimal glands. During apoptosis of these glandular cells, alpha-fodrin is cleaved, triggering an autoimmune response. These antibodies are particularly useful in diagnosing "seronegative" Sjogren’s patients who test negative for Ro/La. **Analysis of Incorrect Options:** * **Polymyositis:** Characterized by antibodies against aminoacyl-tRNA synthetases, most notably **Anti-Jo-1** [1]. * **Crohn’s Disease:** Associated with **ASCA** (Anti-Saccharomyces cerevisiae antibodies) and occasionally p-ANCA. * **Graves’ Disease:** Driven by **TSHR-Ab** (Thyroid Stimulating Hormone Receptor Antibodies/TSI). **NEET-PG High-Yield Pearls:** * **Most Specific Marker for SS:** Anti-Ro (SS-A) and Anti-La (SS-B) remain the gold standard in criteria, but Anti-alpha fodrin is a specific adjunct. * **Schirmer’s Test:** Used to quantify lacrimal gland hypofunction (<5mm in 5 mins is positive). * **Lip Biopsy:** The most definitive diagnostic test, showing focal lymphocytic sialadenitis (Focus score ≥1). * **Malignancy Risk:** Patients with Sjogren’s have a 40-fold increased risk of developing **B-cell Non-Hodgkin Lymphoma** (MALToma).

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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