Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 21: Pulmonary complications of rheumatoid arthritis include the following except?

A. Pulmonary nodules
B. Mesothelioma (Correct Answer)
C. Fibrosing alveolitis
D. Pleural effusion

Explanation: **Explanation:** Rheumatoid Arthritis (RA) is a systemic inflammatory disorder that frequently involves extra-articular manifestations, with the lungs being a primary target [1]. **Why Mesothelioma is the Correct Answer:** **Mesothelioma** is a primary malignant tumor of the pleura, almost exclusively associated with **asbestos exposure** [4]. It is not a complication of Rheumatoid Arthritis. While RA can cause pleural inflammation (pleuritis), it does not lead to the malignant transformation of mesothelial cells. **Analysis of Incorrect Options:** * **Pulmonary Nodules:** These are well-known features of RA, often occurring in patients with high titers of Rheumatoid Factor [2]. When these nodules occur in the context of coal worker's pneumoconiosis, it is known as **Caplan Syndrome** [3]. * **Fibrosing Alveolitis (Interstitial Lung Disease):** ILD is a common and serious complication of RA. It typically presents as a Usual Interstitial Pneumonia (UIP) pattern, leading to progressive pulmonary fibrosis [1]. * **Pleural Effusion:** This is the most common pleuropulmonary manifestation of RA [1]. A classic NEET-PG diagnostic clue is that RA-related pleural fluid typically has **very low glucose levels** (<30 mg/dL) and low complement levels. **High-Yield Clinical Pearls for NEET-PG:** 1. **Caplan Syndrome:** Combination of RA + Coal Worker's Pneumoconiosis + Multiple peripheral lung nodules [3]. 2. **RA Pleural Fluid:** Characterized by low glucose, high LDH, and low pH. 3. **Drug-Induced Lung Disease:** Remember that **Methotrexate**, a first-line treatment for RA, can itself cause hypersensitivity pneumonitis [1]. 4. **Bronchiolitis Obliterans:** A rare but severe obstructive airway complication seen in RA patients [1].

Question 22: What is the common cardiac lesion found in Systemic Lupus Erythematosus (SLE)?

A. Verrucous endocarditis
B. Valvular incompetence
C. Myocardial fibrosis
D. All of the above (Correct Answer)

Explanation: **Explanation:** Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disorder that can affect all layers of the heart (pericardium, myocardium, and endocardium). While **pericarditis** is the most common clinical cardiac manifestation, the disease frequently involves the valves and myocardium. [1] 1. **Verrucous Endocarditis (Libman-Sacks Endocarditis):** This is the classic, pathognomonic cardiac lesion of SLE. It is characterized by small, sterile, non-bacterial vegetations (verrucae) that can occur on any valvular surface, most commonly the mitral and aortic valves. 2. **Valvular Incompetence:** Chronic inflammation and the healing of Libman-Sacks vegetations often lead to scarring, thickening, and shortening of the valve leaflets, resulting in valvular regurgitation (incompetence). [2] 3. **Myocardial Fibrosis:** SLE can cause myocarditis, which may progress to patchy myocardial fibrosis. This can lead to conduction defects or heart failure. **Why "All of the above" is correct:** SLE is a "pancarditis" disease. Because the pathology involves immune complex deposition and chronic inflammation, it simultaneously affects the endocardium (verrucae), the valve structure (incompetence), and the muscle (fibrosis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cardiac manifestation:** Pericarditis (often presents with pleuritic chest pain and effusion). * **Libman-Sacks Endocarditis:** Vegetations are found on **both sides** of the valve leaflets (unlike Rheumatic Fever, where they are usually on the lines of closure). * **Neonatal Lupus:** Strongly associated with **Congenital Complete Heart Block** due to the transplacental passage of anti-Ro (SS-A) and anti-La (SS-B) antibodies. * **Accelerated Atherosclerosis:** Patients with SLE have a significantly higher risk of premature Coronary Artery Disease (CAD).

Question 23: What is the most commonly affected organ in polyarteritis nodosa?

A. Lungs
B. Kidneys (Correct Answer)
C. Pancreas
D. Spleen

Explanation: **Explanation:** **Polyarteritis Nodosa (PAN)** is a systemic necrotizing vasculitis that typically affects small and medium-sized muscular arteries [1]. **1. Why Kidneys are the Correct Answer:** The **kidneys** are the most frequently involved organ in PAN (occurring in 70–80% of cases) [1]. The pathology involves necrotizing inflammation of the renal arteries, leading to microaneurysms (the classic "string of beads" appearance on angiography) and renal ischemia [1]. This typically manifests as **renovascular hypertension** or renal insufficiency. Importantly, unlike many other vasculitides, PAN is a non-glomerular disease; it affects the vessels, not the glomeruli themselves [2]. **2. Why Other Options are Incorrect:** * **Lungs (A):** This is a high-yield "negative" fact. PAN characteristically **spares the lungs**. If a patient presents with systemic vasculitis and pulmonary involvement (like nodules or hemorrhage), clinicians should suspect Granulomatosis with Polyangiitis (GPA) or Eosinophilic Granulomatosis with Polyangiitis (EGPA) instead. * **Pancreas (C) and Spleen (D):** While PAN can affect any organ (including the GI tract and gallbladder), involvement of the pancreas and spleen is significantly less common than the kidneys, skin, or peripheral nerves. **Clinical Pearls for NEET-PG:** * **Association:** Strongly associated with **Hepatitis B virus (HBV)** infection (HBsAg positivity in ~10-30% of cases). * **ANCA Status:** PAN is typically **ANCA-negative**. * **Clinical Triad:** Often presents with fever, abdominal pain (mesenteric ischemia), and mononeuritis multiplex (foot/wrist drop) [1]. * **Diagnosis:** Confirmed via tissue biopsy or visceral angiography showing microaneurysms.

Question 24: Reactive arthritis is a result of exposure to all of the following infections, EXCEPT:

A. Chlamydia species
B. Campylobacter jejuni
C. Salmonella enteritidis
D. None of the above (Correct Answer)

Explanation: **Explanation:** **Reactive Arthritis (ReA)**, formerly known as Reiter’s Syndrome, is a sterile inflammatory synovitis that develops following a distant infection, typically of the gastrointestinal (GI) or genitourinary (GU) tract [1]. The correct answer is **"None of the above"** because all three listed organisms are classic, well-documented triggers for this condition. 1. **Chlamydia species (Option A):** *Chlamydia trachomatis* is the most common cause of **urogenital** reactive arthritis [1]. It often presents with the classic triad of urethritis, conjunctivitis, and arthritis [2] ("Can't see, can't pee, can't climb a tree"). 2. **Campylobacter jejuni (Option B):** This is a leading cause of **enteric** (post-diarrheal) reactive arthritis [2]. It is a Gram-negative, S-shaped rod often associated with poultry consumption. 3. **Salmonella enteritidis (Option C):** Along with *Shigella* and *Yersinia*, *Salmonella* species are major triggers of post-enteric reactive arthritis following bouts of inflammatory diarrhea [2]. **Clinical Pearls for NEET-PG:** * **HLA-B27 Association:** Approximately 30–50% of patients are HLA-B27 positive; these individuals tend to have more severe, chronic disease [1]. * **Pattern of Arthritis:** It typically presents as an **asymmetric oligoarthritis**, predominantly affecting the large joints of the lower extremities (knees, ankles) [2]. * **Extra-articular Manifestations:** Look for **Keratoderma blennorrhagicum** (vesicular/pustular skin lesions on palms/soles) and **Circinate balanitis** (painless penile ulcers), which are high-yield diagnostic clues [2]. * **Synovial Fluid:** The fluid is sterile (culture-negative), distinguishing it from septic arthritis.

Question 25: Which of the following is NOT seen in primary extraglandular Sjögren's syndrome?

A. Rheumatoid arthritis (Correct Answer)
B. Raynaud's phenomenon
C. Lymphoma
D. Splenomegaly

Explanation: ### Explanation The key to answering this question lies in distinguishing between **Primary** and **Secondary** Sjögren’s Syndrome (SS). **1. Why "Rheumatoid Arthritis" is the correct answer:** Sjögren’s Syndrome is classified into two types: * **Primary SS:** Occurs in isolation, characterized by sicca symptoms (dry eyes/mouth) and potential extraglandular manifestations. * **Secondary SS:** Occurs in the **presence** of another established autoimmune disease, most commonly **Rheumatoid Arthritis (RA)**, followed by SLE or Systemic Sclerosis [1]. By definition, if a patient has Rheumatoid Arthritis, the Sjögren’s is classified as **Secondary**, not Primary. Therefore, RA cannot be a manifestation of Primary SS. **2. Analysis of Incorrect Options:** * **Raynaud's Phenomenon:** This is a common extraglandular manifestation of Primary SS, occurring in approximately 13–30% of patients [2]. * **Lymphoma:** Patients with Primary SS have a **40-fold increased risk** of developing B-cell MALT lymphoma. This is a classic high-yield association. * **Splenomegaly:** This can occur in Primary SS as part of generalized lymphadenopathy or as a precursor to lymphoproliferative disorders. **3. NEET-PG High-Yield Pearls:** * **Most common extraglandular manifestation:** Arthralgia/Arthritis (non-erosive, unlike RA). * **Serology:** Anti-Ro (SS-A) and Anti-La (SS-B) are the hallmark antibodies [3]. * **Diagnosis:** The "Gold Standard" is a **Minor Salivary Gland Biopsy** showing lymphocytic sialadenitis (Focus score ≥1). * **Schirmer’s Test:** Used to quantify decreased tear production (<5 mm in 5 minutes). * **Renal involvement:** Most commonly presents as **Distal Renal Tubular Acidosis (Type 1 RTA)**.

Question 26: Thymomas may be associated with all of the following, except?

A. Myasthenia Gravis
B. Hypergammaglobulinemia (Correct Answer)
C. Panhypopituitarism
D. Systemic Lupus Erythematosus (SLE)

Explanation: ### Explanation Thymomas are epithelial neoplasms of the thymus gland and are notorious for their association with various paraneoplastic autoimmune syndromes. **Why Option B is the Correct Answer:** Thymomas are characteristically associated with **Hypogammaglobulinemia** (specifically **Good’s Syndrome**), not hypergammaglobulinemia. Good’s syndrome is a rare immunodeficiency triad consisting of thymoma, hypogammaglobulinemia, and low or absent B-cells. This leads to an increased susceptibility to bacterial, viral, and fungal infections. **Analysis of Other Options:** * **A. Myasthenia Gravis:** This is the most common association. Approximately 30–45% of patients with thymoma have Myasthenia Gravis (MG), and conversely, about 10–15% of MG patients have a thymoma [1], [2]. Screening for internal thymomas via thoracic CT is standard in MG patients [1]. * **C. Panhypopituitarism:** While rare, thymomas have been documented in association with various endocrine disorders and multi-organ autoimmunity, including cases of lymphocytic hypophysitis leading to panhypopituitarism. * **D. Systemic Lupus Erythematosus (SLE):** Thymomas are associated with a wide spectrum of autoimmune connective tissue diseases, including SLE, polymyositis, and rheumatoid arthritis, due to the failure of central tolerance and T-cell maturation within the neoplastic thymus. **High-Yield Clinical Pearls for NEET-PG:** 1. **Good’s Syndrome:** Remember the triad: Thymoma + Hypogammaglobulinemia + B-cell deficiency. 2. **Pure Red Cell Aplasia (PRCA):** About 5–10% of thymoma patients develop PRCA; it is a classic "favorite" association in exams. 3. **Imaging:** Contrast-enhanced CT (CECT) of the chest is the gold standard for evaluating an anterior mediastinal mass [1]. 4. **Surgical Management:** Thymectomy is indicated for thymomas, but it does not always guarantee the resolution of associated autoimmune symptoms (like MG).

Question 27: Patients with antiphospholipid antibodies may manifest with any of the following, except:

A. Venous thrombosis
B. Arterial thrombosis
C. Hemolytic anemia
D. Thrombocytosis (Correct Answer)

Explanation: **Explanation:** Antiphospholipid Syndrome (APS) is an autoimmune prothrombotic state characterized by the presence of antiphospholipid antibodies (aPL) such as Lupus Anticoagulant, Anti-cardiolipin, and Anti-̢2-glycoprotein I. **Why Thrombocytosis is the Correct Answer:** In APS, the hallmark hematological finding is **Thrombocytopenia** (low platelet count) [2], not thrombocytosis. This occurs because the antibodies bind to platelets, leading to their activation, sequestration, and subsequent destruction. Therefore, thrombocytosis is not a manifestation of this condition. **Analysis of Incorrect Options:** * **Venous Thrombosis (A):** This is the most common clinical manifestation of APS. It typically presents as Deep Vein Thrombosis (DVT) or Pulmonary Embolism. * **Arterial Thrombosis (B):** APS is unique because it causes both venous and arterial clots. Arterial involvement often manifests as a Stroke or Transient Ischemic Attack (TIA) in young patients. * **Hemolytic Anemia (C):** Autoimmune hemolytic anemia (AIHA) is a recognized secondary feature of APS, often associated with Evans Syndrome (AIHA + Thrombocytopenia). **High-Yield Clinical Pearls for NEET-PG:** * **Obstetric Manifestations:** Recurrent pregnancy loss (usually >10 weeks), premature births due to eclampsia, or placental insufficiency. * **Laboratory Paradox:** APS causes a **prolonged aPTT** *in vitro* (due to interference with phospholipids in the test), but causes **thrombosis** *in vivo*. * **Libman-Sacks Endocarditis:** Non-bacterial verrucous vegetations on heart valves can be seen in APS/SLE. * **Livedo Reticularis:** A lace-like purplish skin discoloration is a common cutaneous sign [1].

Question 28: All of the following are true regarding Wegener's granulomatosis except?

A. Affects large size blood vessels (Correct Answer)
B. May affect lungs and kidneys
C. Necrotizing granuloma may be seen on microscopy
D. PR3-ANCAs are present in up to 95% of cases

Explanation: Explanation: Wegener’s Granulomatosis, now known as Granulomatosis with Polyangiitis (GPA), is a systemic necrotizing vasculitis. 1. Why Option A is the correct answer (False statement): GPA is classified as a small-vessel vasculitis. It primarily affects capillaries, venules, and arterioles. It does not involve large-sized blood vessels (like the aorta or its major branches), which are typically affected in conditions like Takayasu arteritis or Giant Cell Arteritis. 2. Analysis of other options: * Option B (Lungs and Kidneys): GPA is characterized by a classic triad of involvement: Upper Respiratory Tract (sinusitis, saddle nose deformity), Lower Respiratory Tract (lung nodules, cavitation), and Kidneys (Pauci-immune Crescentic Glomerulonephritis) [1]. * Option C (Necrotizing Granuloma): The hallmark histopathological feature of GPA is the presence of necrotizing "geographic" granulomas and vasculitis [1]. * Option D (PR3-ANCA): GPA is strongly associated with c-ANCA (anti-proteinase 3). In active generalized disease, PR3-ANCA sensitivity is approximately 90-95%. Clinical Pearls for NEET-PG: * Classic Triad: Upper respiratory tract + Lungs + Kidneys. * Marker: c-ANCA (PR3-ANCA) is highly specific. * Drug of Choice: Induction with Corticosteroids + Cyclophosphamide (or Rituximab). * Radiology: Chest X-ray often shows bilateral nodular infiltrates with cavitation [1]. * Differentiating Feature: Unlike Churg-Strauss (EGPA), GPA does not typically present with asthma or eosinophilia [1].

Question 29: A 40-year-old male presents with an upper respiratory tract infection (URTI), hemoptysis, and an elevated c-ANCA value. What is the most likely diagnosis?

A. Churg-Strauss syndrome
B. Wegener's granulomatosis (Correct Answer)
C. Microscopic polyangiitis
D. Goodpasture syndrome

Explanation: The clinical triad of **upper respiratory tract involvement** (sinusitis, otitis media, or saddle nose deformity), **lower respiratory tract involvement** (hemoptysis, nodules), and **renal involvement** (glomerulonephritis) is classic for **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA) [1]. The presence of **c-ANCA** (anti-proteinase 3 antibodies) is highly specific (approx. 90%) for this condition, making it the most likely diagnosis. **Analysis of Incorrect Options:** * **Churg-Strauss Syndrome (EGPA):** Characterized by asthma, peripheral eosinophilia, and **p-ANCA** (anti-MPO) [2]. It typically lacks the destructive upper airway lesions seen in GPA. * **Microscopic Polyangiitis (MPA):** A small-vessel vasculitis that involves the lungs and kidneys but characteristically **spares the upper respiratory tract** [1]. It is most commonly associated with **p-ANCA**. * **Goodpasture Syndrome:** Presents with a pulmonary-renal syndrome (hemoptysis and hematuria) but is caused by **anti-GBM antibodies**, not ANCA [1]. It does not involve the upper respiratory tract (sinuses/ears). **NEET-PG High-Yield Pearls:** * **GPA Triad:** Upper Respiratory + Lower Respiratory + Kidneys. * **Serology:** c-ANCA (PR3) is the marker for GPA; p-ANCA (MPO) is for MPA and EGPA [2]. * **Biopsy Gold Standard:** Shows necrotizing granulomatous inflammation [1]. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab) [2]. * **Radiology:** GPA often shows "cavitary nodules" on a chest X-ray [1].

Question 30: Which of the following is associated with vasculitis of medium-sized vessels?

A. Temporal arteritis
B. Wegener's granulomatosis (Correct Answer)
C. Classic polyarteritis nodosa (PAN)
D. Tuberous sclerosis

Explanation: **Explanation:** The classification of vasculitis is primarily based on the size of the predominant vessel involved (Large, Medium, or Small). **Why Option B is Correct:** **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA) is classified as a **Small Vessel Vasculitis**. However, it is unique because it frequently involves **medium-sized arteries** in addition to capillaries, venules, and arterioles. In the context of NEET-PG questions, GPA is often grouped under the "Small and Medium Vessel" category due to its systemic nature and necrotizing granulomatous inflammation of the respiratory tract and kidneys. **Analysis of Incorrect Options:** * **A. Temporal Arteritis:** This is a classic **Large Vessel Vasculitis**. It primarily affects the aorta and its major branches, particularly the extracranial branches of the carotid artery. * **C. Classic Polyarteritis Nodosa (PAN):** While PAN is the *prototypical* **Medium Vessel Vasculitis**, the question asks for an association. In many standardized exams, if GPA is the keyed answer, it highlights the overlap between small and medium vessel involvement. (Note: In strict Chapel Hill criteria, PAN is medium-vessel, while GPA is small-vessel; however, GPA’s involvement of medium arteries is a recognized pathological feature). * **D. Tuberous Sclerosis:** This is a **neurocutaneous syndrome** (phakomatosis) characterized by hamartomas in multiple organs. It is not a primary vasculitis. **High-Yield Clinical Pearls for NEET-PG:** * **GPA Triad:** Upper respiratory tract (sinusitis/saddle nose), Lower respiratory tract (hemoptysis/cavitation), and Renal involvement (pauci-immune GN). * **Serology:** GPA is strongly associated with **c-ANCA (PR3-ANCA)**. * **Large Vessel:** Giant Cell (Temporal) Arteritis, Takayasu Arteritis. * **Medium Vessel:** PAN, Kawasaki Disease. * **Small Vessel:** GPA, Microscopic Polyangiitis, Churg-Strauss (EGPA), Henoch-Schönlein Purpura.

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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