Rheumatology and Immunology Practice Questions

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

Churg-Strauss syndrome. ### 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.

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

Leucocytosis. 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].

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

Gout. 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].

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

Progressive systemic sclerosis. 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).

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

Causes pleural effusion with low sugar.. ### 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].

Q: 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?

Shigella. **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].

Q: Antineutrophil cytoplasmic antibody-associated vasculitides include all except?

Polyarteritis nodosa. **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.

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

Sjogren's syndrome. **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).

Question 1

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

Accepted Answer

Churg-Strauss syndrome

Answer

Goodpasture syndrome

Answer

Cryptogenic fibrosing alveolitis

Answer

Sarcoidosis

Question 2

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

Accepted Answer

Leucocytosis

Answer

Oral ulcers

Answer

Psychosis

Answer

Discoid rash

Question 3

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

Accepted Answer

Gout

Answer

Multiple myeloma

Answer

Cystinosis

Answer

Eales disease

Question 4

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

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Rheumatoid Arthritis

Answer

Reiter's Disease

Answer

Polyarteritis Nodosa

Question 5

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

Accepted Answer

Progressive systemic sclerosis

Answer

Dermatomyositis/polymyositis

Answer

Rheumatoid arthritis

Answer

Systemic lupus erythematosus

Question 6

Which of the following statements is true regarding Rheumatoid arthritis?

Accepted Answer

Causes pleural effusion with low sugar.

Answer

Typically involves small and large joints symmetrically but spares the cervical spine.

Answer

Pulmonary nodules are absent.

Answer

Enthesopathy is prominent.

Question 7

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?

Accepted Answer

Shigella

Answer

Campylobacter

Answer

E coli

Answer

Yersinia

Question 8

Antineutrophil cytoplasmic antibody-associated vasculitides include all except?

Accepted Answer

Polyarteritis nodosa

Answer

Wegener granulomatosis

Answer

Microscopic polyangiitis

Answer

Churg-Strauss syndrome

Question 9

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?

Accepted Answer

Osteoporosis

Answer

Multiple myeloma

Answer

Metastatic breast cancer

Answer

Vitamin D deficiency

Question 10

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

Accepted Answer

Sjogren's syndrome

Answer

Polymyositis

Answer

Crohn's disease

Answer

Graves' disease

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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