Rheumatology and Immunology Practice Questions

Q: Pulmonary complications of rheumatoid arthritis include the following except?

Mesothelioma. **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].

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

All of the above. **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).

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

Kidneys. **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.

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

None of the above. **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.

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

Rheumatoid arthritis. ### 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)**.

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

Hypergammaglobulinemia. ### 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).

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

Thrombocytosis. **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].

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

Affects large size blood vessels. 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].

Q: 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?

Wegener's granulomatosis. 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 1

Pulmonary complications of rheumatoid arthritis include the following except?

Accepted Answer

Mesothelioma

Answer

Pulmonary nodules

Answer

Fibrosing alveolitis

Answer

Pleural effusion

Question 2

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

Accepted Answer

All of the above

Answer

Verrucous endocarditis

Answer

Valvular incompetence

Answer

Myocardial fibrosis

Question 3

What is the most commonly affected organ in polyarteritis nodosa?

Accepted Answer

Kidneys

Answer

Lungs

Answer

Pancreas

Answer

Spleen

Question 4

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

Accepted Answer

None of the above

Answer

Chlamydia species

Answer

Campylobacter jejuni

Answer

Salmonella enteritidis

Question 5

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

Accepted Answer

Rheumatoid arthritis

Answer

Raynaud's phenomenon

Answer

Lymphoma

Answer

Splenomegaly

Question 6

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

Accepted Answer

Hypergammaglobulinemia

Answer

Myasthenia Gravis

Answer

Panhypopituitarism

Answer

Systemic Lupus Erythematosus (SLE)

Question 7

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

Accepted Answer

Thrombocytosis

Answer

Venous thrombosis

Answer

Arterial thrombosis

Answer

Hemolytic anemia

Question 8

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

Accepted Answer

Affects large size blood vessels

Answer

May affect lungs and kidneys

Answer

Necrotizing granuloma may be seen on microscopy

Answer

PR3-ANCAs are present in up to 95% of cases

Question 9

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?

Accepted Answer

Wegener's granulomatosis

Answer

Churg-Strauss syndrome

Answer

Microscopic polyangiitis

Answer

Goodpasture syndrome

Question 10

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

Accepted Answer

Wegener's granulomatosis

Answer

Temporal arteritis

Answer

Classic polyarteritis nodosa (PAN)

Answer

Tuberous sclerosis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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