Rheumatology and Immunology Practice Questions

Q: Which of the following are features of systemic sclerosis?

All of the above. Explanation: Systemic Sclerosis (SSc) is a chronic multisystem autoimmune disorder characterized by vascular dysfunction and progressive fibrosis of the skin and internal organs. The correct answer is **All of the above** because each option represents a classic cutaneous or systemic manifestation of the disease. 1. **Calcinosis (Option A):** This refers to the deposition of insoluble calcium salts in the subcutaneous tissues, often occurring at pressure points like fingertips or elbows. It is a hallmark feature of the **CREST syndrome** (Limited Cutaneous SSc). 2. **Sclerodactyly (Option B):** This is the localized thickening and tightening of the skin of the fingers or toes [1]. It often begins with an "edematous phase" (puffy fingers) before progressing to the fibrotic phase, leading to a "claw-like" hand deformity and loss of motion [1]. 3. **Melanin Deposition (Option C):** Hyperpigmentation is a frequently overlooked feature of SSc. It often presents as a diffuse, generalized darkening of the skin (due to increased melanin production) that may precede or accompany skin thickening. A classic "salt-and-pepper" appearance (vitiligo-like areas of depigmentation alongside hyperpigmentation) is highly characteristic. **High-Yield Clinical Pearls for NEET-PG:** * **CREST Syndrome:** Calcinosis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. * **Antibody Associations:** * **Anti-Centromere:** Highly specific for Limited SSc (CREST). * **Anti-Scl-70 (Anti-topoisomerase I):** Associated with Diffuse SSc and increased risk of Interstitial Lung Disease (ILD). * **Anti-RNA Polymerase III:** Associated with Diffuse SSc and a high risk for **Scleroderma Renal Crisis**. * **Leading Cause of Death:** Lung involvement (Interstitial Lung Disease or Pulmonary Arterial Hypertension) has replaced renal crisis as the leading cause of mortality in SSc patients.

Q: Rheumatoid arthritis pericarditis is typically characterized by which type of inflammation?

Fibrinous pericarditis. **Explanation:** **Rheumatoid Arthritis (RA)** is a systemic autoimmune disorder where extra-articular manifestations are common [1]. Cardiac involvement occurs in approximately 30–50% of patients, though it is often clinically silent. **Why Fibrinous Pericarditis is Correct:** The hallmark of RA-associated pericardial involvement is **fibrinous or "bread-and-butter" pericarditis**. Pathologically, this involves the deposition of fibrin on the pericardial surfaces due to chronic inflammation. While many patients are asymptomatic, those who are symptomatic present with pleuritic chest pain and a pericardial friction rub. Histologically, it may show rheumatoid nodules or non-specific granulomatous inflammation. **Analysis of Incorrect Options:** * **A. Serous pericarditis:** Typically seen in non-infectious inflammatory conditions like Uremia or early viral infections. It lacks the thick fibrin exudate characteristic of RA. * **C. Serofibrinous pericarditis:** While there is an overlap, "Fibrinous" is the specific pathological descriptor most associated with the classic "shaggy" appearance of the pericardium in RA and Uremia. * **D. Adhesive pericarditis:** This is a late-stage sequela where the pericardial layers stick together, often following suppurative or tuberculous pericarditis, rather than the primary inflammatory stage of RA. **High-Yield Clinical Pearls for NEET-PG:** * **Pericardial Fluid Analysis in RA:** Characteristically shows **very low glucose levels** (<30 mg/dL), low complement levels (C3, C4), and high LDH. This "low glucose" profile is a classic exam favorite. * **Most Common Cardiac Manifestation in RA:** Pericarditis (though usually asymptomatic). * **Most Common Cause of Death in RA:** Ischemic Heart Disease (due to accelerated atherosclerosis). * **Other Fibrinous Pericarditis Causes:** Post-MI (Dressler Syndrome), Uremia, and Systemic Lupus Erythematosus (SLE).

Q: ASLO titres are used in the diagnosis of which of the following conditions?

Acute rheumatic fever. ### Explanation **Correct Answer: B. Acute Rheumatic Fever** **Why it is correct:** Anti-streptolysin O (ASLO) is an antibody directed against **Streptolysin O**, an exotoxin produced by **Group A Beta-hemolytic Streptococci (GABS)**. Acute Rheumatic Fever (ARF) is a non-suppurative sequela of a GABS pharyngeal infection. According to the **Revised Jones Criteria**, evidence of a preceding streptococcal infection is essential for the diagnosis of ARF (except in cases of chorea or indolent carditis) [1]. An elevated or rising ASLO titre is the most commonly used laboratory evidence to confirm this prior infection. **Why the other options are incorrect:** * **A. Acute Rheumatoid Arthritis:** This is an autoimmune chronic inflammatory disorder. Diagnosis relies on clinical features, Rheumatoid Factor (RF), and Anti-CCP antibodies, not streptococcal markers [1]. * **C. Ankylosing Spondylitis:** This is a seronegative spondyloarthropathy strongly associated with the **HLA-B27** gene. It involves the sacroiliac joints and spine; ASLO has no diagnostic role here. * **D. Osteoarthritis:** This is a degenerative joint disease caused by "wear and tear" of articular cartilage. It is not inflammatory or post-infectious, so ASLO titres remain normal. **High-Yield Clinical Pearls for NEET-PG:** * **Peak Timing:** ASLO titres begin to rise 1–3 weeks after infection, peak at 3–5 weeks, and may persist for months. * **Skin Infections:** ASLO titres often do **not** rise significantly following streptococcal pyoderma (impetigo). In such cases, the **Anti-DNase B** test is more reliable. * **Diagnostic Threshold:** A single titre is less significant than a rising titre; however, a value >200 IU/ml in adults or >333 IU/ml in children is generally considered elevated. * **Other Markers:** If ASLO is negative but ARF is strongly suspected, order Anti-DNase B or Anti-hyaluronidase.

Q: Heberden node denotes involvement of which joint?

Distal interphalangeal joint. **Explanation:** **Heberden’s nodes** are a classic clinical hallmark of **Osteoarthritis (OA)**. They represent bony overgrowths (osteophytes) that occur specifically at the **Distal Interphalangeal (DIP) joints** [1]. These nodes are caused by repeated mechanical stress and cartilage degradation, leading to reactive bone formation. They are more common in women and often have a strong genetic predisposition [1]. **Analysis of Options:** * **Option A (Correct):** Heberden’s nodes are pathognomonic for OA involvement of the **DIP joints** [1]. * **Option B (Incorrect):** Bony enlargements at the **Proximal Interphalangeal (PIP) joints** are known as **Bouchard’s nodes** [1]. While also seen in OA, they are distinct from Heberden’s nodes. * **Option C (Incorrect):** The **Metacarpophalangeal (MCP) joints** are typically spared in primary Osteoarthritis. Involvement of the MCP joints is a classic feature of **Rheumatoid Arthritis (RA)**. * **Option D (Incorrect):** The first **Metatarsophalangeal (MTP) joint** is the most common site for **Gout** (Podagra) and can also be affected by OA (Hallux rigidus), but it is not the site of Heberden’s nodes. **High-Yield Clinical Pearls for NEET-PG:** * **DIP involvement:** Think Osteoarthritis or Psoriatic Arthritis. (Note: RA characteristically *spares* the DIP). * **Nodal OA:** The presence of Heberden’s nodes often signifies a specific subset of OA called "Nodal Generalized Osteoarthritis" [1]. * **Radiological findings in OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [1]. * **Hand Deformities:** Remember the mnemonic: **H**eberden = **H**igh (Distal); **B**ouchard = **B**elow (Proximal).

Q: Which of the following findings is seen more commonly in rheumatoid arthritis than in ankylosing spondylitis?

Autoantibody against IgG. **Explanation:** The correct answer is **Autoantibody against IgG**, commonly known as **Rheumatoid Factor (RF)**. 1. **Why it is correct:** Rheumatoid Factor is an autoantibody (usually IgM) directed against the Fc portion of the patient's own IgG. It is a hallmark of **Rheumatoid Arthritis (RA)**, found in approximately 70-80% of patients. In contrast, **Ankylosing Spondylitis (AS)** belongs to the group of **Seronegative Spondyloarthritides**, which are characterized by the absence of RF [1]. 2. **Analysis of Incorrect Options:** * **HLA-B27 haplotype:** This is strongly associated with AS (>90% of cases) and other seronegative spondyloarthritides [1], whereas RA is primarily associated with **HLA-DR4**. * **Sacroiliitis:** This is the radiographic hallmark of AS and is essential for its diagnosis [1]. RA typically spares the sacroiliic joints and involves the small joints of the hands and feet. * **Increased incidence in men:** AS is significantly more common in males (approx. 3:1 ratio). Conversely, RA is 3 times more common in **females**. **Clinical Pearls for NEET-PG:** * **Joint Involvement:** RA involves the **PIP and MCP** joints (spares DIP); AS involves the **axial skeleton** and large proximal joints. * **Cervical Spine:** RA can cause **atlantoaxial subluxation**; AS leads to a "Bamboo spine" due to syndesmophytes [1]. * **Extra-articular:** RA is associated with subcutaneous nodules and interstitial lung disease; AS is classically associated with **acute anterior uveitis** and aortic regurgitation [1]. * **Serology:** Anti-CCP is more specific for RA than RF.

Q: All of the following are seen in Systemic Lupus Erythematosus (SLE) except?

Normal complement level. **Explanation:** In **Systemic Lupus Erythematosus (SLE)**, the hallmark of the disease is the formation of immune complexes [4]. The correct answer is **Normal complement level** because SLE is characterized by **low complement levels (Hypocomplementemia)**, specifically C3 and C4 [2]. This occurs because the classical complement pathway is hyper-activated to clear immune complexes, leading to the "consumption" of these proteins [2]. Monitoring C3 and C4 levels is a high-yield clinical marker for assessing **disease activity** and lupus nephritis flares [2]. **Analysis of Incorrect Options:** * **Psychosis:** This is a manifestation of **Neuropsychiatric SLE (NPSLE)**. It is included in the ACR/SLICC diagnostic criteria. Other CNS features include seizures and cognitive dysfunction. * **Pleurisy:** Serositis (pleuritis or pericarditis) is a classic diagnostic criterion [2]. Patients often present with pleuritic chest pain and pleural effusions. * **Recurrent Miscarriage:** This is frequently seen in SLE patients who have co-existing **Antiphospholipid Antibody Syndrome (APS)**. Prothrombotic states lead to placental infarction and fetal loss [1]. **NEET-PG High-Yield Pearls:** 1. **Most Specific Antibody:** Anti-dsDNA and Anti-Smith (Anti-dsDNA levels also correlate with disease activity/nephritis) [2], [3]. 2. **Most Sensitive Antibody:** ANA (Best screening test) [2], [3]. 3. **Drug-Induced Lupus:** Characterized by **Anti-Histone antibodies**; notably, complement levels and CNS/Renal involvement are usually **normal** in the drug-induced form. 4. **Libman-Sacks Endocarditis:** Non-bacterial verrucous vegetations on both sides of the heart valves seen in SLE.

Question 1

Which of the following are features of systemic sclerosis?

Accepted Answer

All of the above

Answer

Calcinosis

Answer

Sclerodactyly

Answer

Melanin deposition

Question 2

Rheumatoid arthritis pericarditis is typically characterized by which type of inflammation?

Accepted Answer

Fibrinous pericarditis

Answer

Serous pericarditis

Answer

Serofibrinous pericarditis

Answer

Adhesive pericarditis

Question 3

ASLO titres are used in the diagnosis of which of the following conditions?

Accepted Answer

Acute rheumatic fever

Answer

Acute rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Osteoarthritis

Question 4

In a pregnant woman, all of the following drugs can be given for Systemic Lupus Erythematosus (SLE), EXCEPT:

Accepted Answer

Methotrexate

Answer

Sulfasalazine

Answer

Hydroxychloroquine

Answer

Prednisone

Question 5

A 68-year-old man presents with an acutely red and swollen right great toe with no history of trauma. Which of the following findings is most useful for making a diagnosis of gout in this patient?

Accepted Answer

Good response to colchicine trial

Answer

Persistent elevation of serum uric acid

Answer

Radiograph showing marginal joint erosion in the first metatarsophalangeal (MTP) joint

Answer

An associated right ankle effusion

Question 6

Heberden node denotes involvement of which joint?

Accepted Answer

Distal interphalangeal joint

Answer

Proximal interphalangeal joint

Answer

Metacarpophalangeal joint

Answer

Metatarsophalangeal joint

Question 7

Macrophage activation syndrome is seen in association with which of the following conditions?

Accepted Answer

Systemic lupus erythematosus

Answer

Systemic sclerosis

Answer

Sweet's syndrome

Answer

Polyarteritis nodosa

Question 8

An 11-year-old boy presented with a sore throat, no cough, tonsillar exudates, and a fever of 38.3°C three weeks ago. A throat culture was positive for group A beta-hemolytic Streptococcus. On follow-up examination, the child is afebrile. His pulse is 85/min, respirations are 18/min, and blood pressure is 90/50 mm Hg. On auscultation, a diastolic mitral murmur is audible, and there are diffuse rales over both lungs. Over the next 2 days, he has several episodes of atrial fibrillation accompanied by signs of acute left ventricular failure. Which of the following pathologic changes occurring in this child's heart is most likely to be the cause of the left ventricular failure?

Accepted Answer

Myocarditis

Answer

Amyloidosis

Answer

Fibrinous pericarditis

Answer

Mitral valve fibrosis

Question 9

Which of the following findings is seen more commonly in rheumatoid arthritis than in ankylosing spondylitis?

Accepted Answer

Autoantibody against IgG

Answer

HLA-B27 haplotype

Answer

Sacroiliitis

Answer

Increased incidence in men

Question 10

All of the following are seen in Systemic Lupus Erythematosus (SLE) except?

Accepted Answer

Normal complement level

Answer

Psychosis

Answer

Pleurisy

Answer

Recurrent miscarriage

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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