Rheumatology and Immunology Practice Questions

Q: Which of the following joints is typically spared in acute gout?

Glenohumeral joint. Gout is a crystal-induced arthropathy caused by the deposition of monosodium urate (MSU) crystals [1]. It has a strong predilection for **peripheral joints** in the lower extremities, primarily due to lower intra-articular temperatures and prior minor trauma, which facilitate crystal precipitation. **Why the Glenohumeral Joint is the Correct Answer:** The **glenohumeral (shoulder) joint** is a large, proximal, axial joint with high vascularity and a higher core temperature. These factors make it an unfavorable site for MSU crystal deposition. While gout can theoretically affect any joint in advanced chronic stages (tophaceous gout), it is **typically spared** during acute attacks. Involvement of the shoulder should prompt a clinician to consider alternative diagnoses like Calcium Pyrophosphate Deposition Disease (CPPD) or septic arthritis. **Analysis of Incorrect Options:** * **A. Metatarsophalangeal (MTP) joint:** The 1st MTP joint is the most common site for an initial attack (Podagra), affected in ~50% of first episodes and ~90% of patients eventually [1]. * **C. Ankle joint:** A very common site for acute gout, often presenting as part of a monoarticular or oligoarticular lower limb distribution. * **D. Knee joint:** The second most common site for acute gout after the 1st MTP joint. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Polarized light microscopy showing **needle-shaped, negatively birefringent** crystals (yellow when parallel to the axis). * **Radiology:** "Punced-out" erosions with overhanging edges (**Martel’s sign**) are characteristic of chronic gout. * **Acute Management:** NSAIDs (first-line), Colchicine, or Corticosteroids. * **Note:** Never start or stop Allopurinol during an acute attack, as fluctuating serum urate levels can prolong the episode.

Q: Which one of the following is not a characteristic feature of rheumatoid arthritis?

Sacroiliitis. **Explanation:** **Rheumatoid Arthritis (RA)** is a chronic, systemic inflammatory disorder characterized primarily by symmetrical, erosive polyarthritis that typically affects small joints. **Why Sacroiliitis is the Correct Answer:** Sacroiliitis (inflammation of the sacroiliac joints) is a hallmark feature of **Seronegative Spondyloarthropathies** (such as Ankylosing Spondylitis, Psoriatic Arthritis, and Reactive Arthritis) [1]. In contrast, Rheumatoid Arthritis characteristically **spares the axial skeleton**, with the notable exception of the **Cervical Spine** (C1-C2 subluxation). Therefore, sacroiliitis is not a feature of RA. **Analysis of Incorrect Options:** * **Metacarpophalangeal (MCP) joint involvement:** This is a classic feature of RA. It typically involves the MCP, PIP (proximal interphalangeal), and MTP joints, while characteristically sparing the DIP (distal interphalangeal) joints [1]. * **Symmetrical arthritis:** RA is defined by its symmetrical distribution (affecting the same joint areas on both sides of the body), which helps distinguish it from the often asymmetrical presentation of osteoarthritis or gout. * **Positive Rheumatoid Factor (RF):** Approximately 70-80% of patients with RA are seropositive for RF. While not 100% specific, it remains a key diagnostic criterion. **High-Yield Clinical Pearls for NEET-PG:** * **Joint Sparing:** RA spares the DIP joints and the Lumbar/Sacral spine [1]. * **Specific Marker:** Anti-CCP (Anti-cyclic citrullinated peptide) antibodies are more specific for RA than Rheumatoid Factor. * **Deformities:** Look for "Z-deformity" of the thumb, Swan-neck deformity, and Boutonniere deformity in clinical vignettes. * **Morning Stiffness:** In RA, stiffness typically lasts **>1 hour**, improving with activity.

Q: A triad of skin lesions, asymmetric mononeuritis multiplex, and eosinophilia is seen in which condition?

Churg-Strauss syndrome. **Explanation:** The clinical triad of **skin lesions** (often palpable purpura or nodules), **asymmetric mononeuritis multiplex**, and **peripheral eosinophilia** [1] is a classic presentation of **Churg-Strauss syndrome**, now formally known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**. EGPA is a small-to-medium vessel necrotizing vasculitis [1]. The hallmark of the disease is the presence of asthma, allergic rhinitis, and marked eosinophilia (>10% of total WBC count). Mononeuritis multiplex (e.g., foot drop or wrist drop) occurs due to vasculitis of the *vasa nervorum*, affecting approximately 75% of patients. **Analysis of Incorrect Options:** * **A. Cryoglobulinemic Vasculitis:** Characterized by the triad of purpura, arthralgia, and myalgia (Meltzer’s triad). It is strongly associated with Hepatitis C but does not typically feature eosinophilia. * **B. Polyarteritis Nodosa (PAN):** While PAN causes mononeuritis multiplex and skin lesions (livedo reticularis), it is **not** associated with eosinophilia or pulmonary involvement (asthma). It is frequently linked to Hepatitis B. * **D. Giant Cell Arteritis:** A large-vessel vasculitis primarily affecting the elderly. Key features include jaw claudication, scalp tenderness, and visual loss, with an elevated ESR but no eosinophilia. **NEET-PG High-Yield Pearls:** * **ANCA Status:** EGPA is p-ANCA (anti-MPO) positive in about 40-50% of cases [1]. * **Phases of EGPA:** 1. Prodromal (Asthma/Rhinitis) → 2. Eosinophilic phase → 3. Vasculitic phase. * **Cardiac Involvement:** The most common cause of mortality in EGPA is myocardial inflammation/fibrosis. * **Biopsy:** Shows extravascular granulomas and eosinophilic infiltration [1].

Q: Primary osteoarthritis affects all joints except:

Metacarpophalangeal joint. **Explanation:** Primary Osteoarthritis (OA) is a chronic degenerative disorder of the articular cartilage, typically associated with aging and mechanical "wear and tear." It characteristically involves **weight-bearing joints** and specific small joints of the hand. **Why the Metacarpophalangeal (MCP) joint is the correct answer:** Primary OA characteristically **spares** the MCP joints, the wrists, and the elbows. If a patient presents with involvement of the MCP joints, clinicians must investigate for secondary causes, most notably **Rheumatoid Arthritis** (where MCP involvement is a hallmark) or metabolic conditions like **Hemochromatosis** (the "Iron-handler’s grip"). **Analysis of incorrect options:** * **Hip and Knee Joints (Options A & B):** These are the most common sites for primary OA due to the constant mechanical stress of weight-bearing. The knee is the most frequently affected large joint. * **Distal Interphalangeal (DIP) Joint (Option C):** This is a classic site for primary OA. Involvement here often leads to the formation of **Heberden’s nodes**. The Proximal Interphalangeal (PIP) joints are also commonly affected (Bouchard’s nodes). **NEET-PG High-Yield Pearls:** * **Nodal Distribution:** Primary OA typically involves the DIP, PIP, and the **1st Carpometacarpal (CMC) joint** (base of the thumb), leading to a "squared hand" appearance. * **Radiological Hallmarks (LOSS):** **L**oss of joint space (asymmetrical), **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **ESR/CRP:** Usually normal in primary OA, helping differentiate it from inflammatory arthritides. * **First-line Management:** Weight reduction and quadriceps strengthening exercises; Paracetamol is the initial drug of choice for pain.

Q: Which of the following crystals are found in pseudogout?

Calcium pyrophosphate dihydrate. **Explanation:** **Pseudogout**, clinically known as **Calcium Pyrophosphate Deposition Disease (CPPD)**, is a crystal-induced arthropathy characterized by the deposition of **Calcium Pyrophosphate Dihydrate (CPPD)** crystals in the joint space and articular cartilage (chondrocalcinosis). * **Why Option B is Correct:** In pseudogout, CPPD crystals are deposited in the synovium and cartilage. Under **polarized microscopy**, these crystals are classically described as **rhomboid-shaped** and show **weak positive birefringence** (appearing blue when parallel to the compensator axis), which is the pathognomonic finding for this condition. * **Why Other Options are Incorrect:** * **Option A (Monosodium urate):** These crystals are found in **Gout**. They are needle-shaped and show strong negative birefringence. * **Option C (Calcium hydroxyapatite):** These are associated with **calcific tendonitis** and Milwaukee Shoulder. They are too small to be seen under light microscopy and require Alizarin Red staining. * **Option D (Alkaline phosphatase):** This is an enzyme involved in bone metabolism and mineralization, not a crystal found in joint aspirates. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Joint:** The **Knee** is the most frequently affected joint in pseudogout (unlike Gout, which favors the 1st MTP joint). * **Radiology:** Look for **Chondrocalcinosis** (linear calcification of articular cartilage or menisci). * **Associations:** Pseudogout is often associated with metabolic conditions like **Hyperparathyroidism, Hemochromatosis, Hypomagnesemia,** and **Hypophosphatasia**. * **Demographics:** It typically affects the elderly (>65 years).

Q: Which of the following is the most likely diagnosis for the most common form of eye involvement in Rheumatoid Arthritis?

Sjogren's syndrome. **Explanation:** The most common ocular manifestation in Rheumatoid Arthritis (RA) is **Secondary Sjogren’s Syndrome**, specifically presenting as **Keratoconjunctivitis Sicca (KCS)** or dry eye syndrome [1]. It occurs in approximately 15-25% of RA patients. The underlying mechanism involves lymphocytic infiltration of the lacrimal glands, leading to decreased tear production, which results in symptoms of grittiness, burning, and foreign body sensation. **Analysis of Options:** * **Sjogren’s Syndrome (Correct):** As stated, secondary Sjogren’s is the most frequent eye involvement [1]. While **Episcleritis** is the most *specific* ocular manifestation associated with RA activity, it is less common than KCS [1]. * **Episcleritis (Incorrect):** This presents as painless redness of the eye [1]. While classic for RA, its prevalence is lower than that of Sjogren’s. * **Rheumatoid Vasculitis (Incorrect):** This is a severe systemic complication of long-standing RA involving small to medium-sized vessels [1]. While it can cause ocular issues (like peripheral ulcerative keratitis), it is a rare, late-stage complication. * **Felty’s Syndrome (Incorrect):** This is a triad of RA, splenomegaly, and neutropenia [2]. It is a systemic association rather than a primary ocular manifestation. **High-Yield Pearls for NEET-PG:** * **Most Common Eye Finding:** Keratoconjunctivitis Sicca (Secondary Sjogren’s) [1]. * **Most Serious Eye Finding:** Scleritis (can lead to *Scleromalacia Perforans*, which is painless thinning of the sclera) [1]. * **Schirmer’s Test:** Used to quantify tear production (positive if <5mm in 5 minutes). * **Rose Bengal Staining:** Used to identify corneal epithelial damage in KCS.

Q: A 36-year-old male presents with cavitary lung lesions, sinusitis, and mouth ulcers. Urine analysis reveals RBC casts. What is the most likely diagnosis?

Granulomatosis with polyangiitis. The clinical presentation of **Granulomatosis with Polyangiitis (GPA)**, formerly known as Wegener’s Granulomatosis, is classically defined by a "triad" of involvement: the upper respiratory tract, lower respiratory tract, and kidneys. [1] 1. **Upper Respiratory Tract:** Sinusitis, nasal crusting, and mucosal ulcerations (mouth ulcers). 2. **Lower Respiratory Tract:** Cavitary lung lesions (nodules that undergo necrosis). [1] 3. **Kidneys:** Pauci-immune glomerulonephritis, evidenced here by **RBC casts**, indicating active vasculitis in the glomeruli. [3] **Why other options are incorrect:** * **Eosinophilic Granulomatosis with Polyangiitis (EGPA):** Characterized by asthma, peripheral eosinophilia, and migratory pulmonary infiltrates, rather than cavitary lesions and destructive sinusitis. [2] * **IgA Vasculitis (Henoch-Schönlein Purpura):** Typically presents with palpable purpura (lower limbs), abdominal pain, and arthralgia. It is more common in children and does not cause cavitary lung lesions. [2] * **Microscopic Polyangiitis (MPA):** While it causes pulmonary-renal syndrome, it **spares the upper respiratory tract** (no sinusitis/mouth ulcers) and rarely presents with cavitary lesions. [1] **High-Yield Pearls for NEET-PG:** * **Serology:** GPA is strongly associated with **c-ANCA (anti-PR3)**; MPA and EGPA are associated with **p-ANCA (anti-MPO)**. * **Biopsy:** GPA shows granulomatous inflammation; MPA shows non-granulomatous necrotizing vasculitis. [1] * **Classic Sign:** "Saddle nose deformity" due to destruction of the nasal septum. [1] * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab). [2]

Q: Which of the following is not typically seen in extraglandular Sjögren syndrome?

Splenomegaly. Sjögren syndrome (SS) is a chronic autoimmune disorder characterized by lymphocytic infiltration of exocrine glands (sicca symptoms) and potential extraglandular manifestations. **Why Splenomegaly is the Correct Answer:** While Sjögren syndrome involves systemic inflammation, **splenomegaly is not a typical or diagnostic feature** of the disease. If a patient with SS develops significant splenomegaly or lymphadenopathy, it is often a red flag for the development of B-cell lymphoma rather than a standard manifestation of the syndrome itself. **Analysis of Incorrect Options:** * **A. Rheumatoid Arthritis:** This is the most common condition associated with **Secondary Sjögren syndrome**. Approximately 30-50% of RA patients develop secondary SS [1]. * **B. Raynaud Phenomenon:** This is a well-documented extraglandular manifestation, occurring in about 13-37% of SS patients, often predating the sicca symptoms. * **C. Lymphoma:** Patients with SS have a **40-fold increased risk** of developing Non-Hodgkin Lymphoma (specifically MALT lymphoma). This is a classic high-yield association for exams. **High-Yield Clinical Pearls for NEET-PG:** * **Serology:** Positive for **Anti-Ro (SS-A)** and **Anti-La (SS-B)** antibodies. Anti-Ro is associated with an increased risk of neonatal lupus and congenital heart block. * **Diagnostic Gold Standard:** Lip biopsy showing **focal lymphocytic sialadenitis** (Focus score >1). * **Schirmer Test:** Used to quantify decreased lacrimation (<5mm in 5 minutes). * **Mikulicz Syndrome:** Historical term for bilateral enlargement of salivary and lacrimal glands (now often associated with IgG4-related disease or SS). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 678-679.

Question 1

Which of the following joints is typically spared in acute gout?

Accepted Answer

Glenohumeral joint

Answer

Metatarsophalangeal (MTP) joint

Answer

Ankle joint

Answer

Knee joint

Question 2

Which one of the following is not a characteristic feature of rheumatoid arthritis?

Accepted Answer

Sacroiliitis

Answer

Metacarpophalangeal joint involvement

Answer

Symmetrical arthritis

Answer

Positive rheumatoid factor

Question 3

A triad of skin lesions, asymmetric mononeuritis multiplex, and eosinophilia is seen in which condition?

Accepted Answer

Churg-Strauss syndrome

Answer

Cryoglobulinemic vasculitis

Answer

Polyarteritis nodosa

Answer

Giant cell arteritis

Question 4

Primary osteoarthritis affects all joints except:

Accepted Answer

Metacarpophalangeal joint

Answer

Hip Joint

Answer

Knee joint

Answer

Distal interphalangeal joint

Question 5

Which of the following crystals are found in pseudogout?

Accepted Answer

Calcium pyrophosphate dihydrate

Answer

Monosodium urate monohydrate

Answer

Calcium hydroxyapatite

Answer

Alkaline phosphatase

Question 6

A 10-year-old girl complains of persistent redness of the skin over her knuckles and around the nail beds. She describes easy fatigability and can rise only with difficulty from a squatting position. Physical examination reveals erythema over the knuckles and a heliotropic rash. A muscle biopsy shows infiltrates of B and T lymphocytes around blood vessels and in connective tissue of the perimysium. Elevated serum levels of which of the following would be expected in this patient?

Accepted Answer

Creatine kinase

Answer

Alkaline phosphatase

Answer

Alpha-fetoprotein

Answer

Carcinoembryonic antigen

Question 7

A person suffers from B27 associated reactive arthritis, urethritis, and conjunctivitis. Which is the most likely organism involved in this case?

Accepted Answer

Ureaplasma urealyticum

Answer

Borrelia burgdorferi

Answer

Beta-hemolytic streptococci

Answer

Streptococcus bovis

Question 8

Which of the following is the most likely diagnosis for the most common form of eye involvement in Rheumatoid Arthritis?

Accepted Answer

Sjogren's syndrome

Answer

Felty's syndrome

Answer

Rheumatoid vasculitis

Answer

Episcleritis

Question 9

A 36-year-old male presents with cavitary lung lesions, sinusitis, and mouth ulcers. Urine analysis reveals RBC casts. What is the most likely diagnosis?

Accepted Answer

Granulomatosis with polyangiitis

Answer

Eosinophilic granulomatosis with polyangiitis

Answer

IgA vasculitis

Answer

Microscopic polyangiitis

Question 10

Which of the following is not typically seen in extraglandular Sjögren syndrome?

Accepted Answer

Splenomegaly

Answer

Rheumatoid arthritis

Answer

Raynaud phenomenon

Answer

Lymphoma

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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