Rheumatology and Immunology — MCQs
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What is the treatment for the lesions seen in Behcet syndrome?
Multiple cavitary lesions in the lungs, hematuria, and renal insufficiency are features in a patient with:
Extreme widening of the periodontal ligament space on dental radiograph is the characteristic feature of which condition?
A 72-year-old man injures his right knee, which is now swollen and extremely painful to bend. X-rays of the knee rule out a fracture, and joint fluid aspiration reveals an opaque-colored fluid containing rhomboid crystals with weak-positive birefringence. Which of the following is the most appropriate next step in management?
Which condition is associated with Coombs positive hemolytic anemia?
What is the most likely diagnosis of this case?
A 57-year-old man, previously asymptomatic and on no medications, develops a painful left big toe. It is so painful that even the weight of his sheets is excruciating. On examination, there is a swollen red toe. Which of the following medications is relatively contraindicated?
Which of the following statements is FALSE regarding HIV-related arthritis?
Which one of the following disorders is not associated with carpal tunnel syndrome?
Which of the following conditions is characterized by non-deforming arthritis?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 481: What is the treatment for the lesions seen in Behcet syndrome?
- A. Prednisolone
- B. Thalidomide (Correct Answer)
- C. Infliximab
- D. Rituximab
Explanation: Behcet syndrome is a multisystemic, chronic relapsing vasculitis characterized by the triad of oral ulcers, genital ulcers, and uveitis. The management of Behcet syndrome is tailored to the specific organ involvement. **Why Thalidomide is the correct answer:** Thalidomide is highly effective for treating **refractory mucocutaneous lesions** (severe oral and genital ulcers) in Behcet syndrome. It acts as a potent TNF-alpha inhibitor and modulates the immune response. While not first-line due to its teratogenic potential and risk of peripheral neuropathy, it is a classic "textbook" answer for resistant cutaneous manifestations in Behcet’s. **Analysis of Incorrect Options:** * **A. Prednisolone:** While systemic corticosteroids are used for acute flares or major organ involvement (like posterior uveitis or CNS disease), they are generally avoided for long-term management of isolated skin/mucosal lesions due to side effects and lack of sustained remission. * **B. Infliximab:** This TNF-alpha inhibitor is reserved for severe, sight-threatening uveitis or refractory gastrointestinal/neurological Behcet’s. It is not the primary choice for standard mucocutaneous lesions. * **D. Rituximab:** This anti-CD20 monoclonal antibody is not a standard treatment for Behcet syndrome, as the pathogenesis is primarily mediated by T-cells and neutrophils rather than B-cells. **NEET-PG High-Yield Pearls:** * **Pathergy Test:** A unique diagnostic feature where a sterile papule/pustule forms 24–48 hours after a skin prick. * **HLA Association:** Strongly associated with **HLA-B51**. * **First-line for Mucocutaneous:** Colchicine is typically the first-line agent for preventing the recurrence of ulcers. * **Vascular Involvement:** Behcet’s is unique among vasculitides as it involves both **arteries and veins** (causing "Pulmonary Artery Aneurysms" and "Venous Thrombosis").
Question 482: Multiple cavitary lesions in the lungs, hematuria, and renal insufficiency are features in a patient with:
- A. Polyarteritis nodosa
- B. Churg-Strauss syndrome
- C. Wegener's granulomatosis (Correct Answer)
- D. Temporal arteritis
Explanation: **Explanation:** The clinical triad of **upper/lower respiratory tract involvement** and **glomerulonephritis** is the hallmark of **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA) [1]. 1. **Why Wegener’s is correct:** GPA is a small-vessel vasculitis characterized by granulomatous inflammation [2]. Lung involvement typically manifests as **multiple nodules** that frequently undergo **cavitation** (seen in 50% of cases) [1]. Renal involvement presents as Pauci-immune Crescentic Glomerulonephritis, leading to **hematuria** and progressive **renal insufficiency** [2]. It is strongly associated with **c-ANCA (anti-PR3) positivity**. 2. **Why the other options are incorrect:** * **Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis that characteristically **spares the lungs** [1]. While it causes renal artery microaneurysms (leading to hypertension/infarcts), it does not typically cause glomerulonephritis or cavitary lung lesions. * **Churg-Strauss Syndrome (EGPA):** While it involves the lungs and kidneys, its hallmark is **peripheral eosinophilia and severe asthma** [1]. Lung lesions are usually transient opacities (Loeffler-like) rather than multiple cavitary nodules. It is associated with **p-ANCA**. * **Temporal Arteritis:** A large-vessel vasculitis that primarily affects the extracranial branches of the carotid artery [3]. It presents with headaches, jaw claudication, and visual loss, not cavitary lung disease or hematuria. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of GPA:** Sinusitis (saddle nose deformity), Cavitary lung nodules, and Glomerulonephritis [1]. * **Serology:** c-ANCA (Proteinase-3) is highly specific for GPA. * **Biopsy:** Shows necrotizing granulomatous vasculitis [1]. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab) [2].
Question 483: Extreme widening of the periodontal ligament space on dental radiograph is the characteristic feature of which condition?
- A. Scleroderma (Correct Answer)
- B. Paget's disease
- C. Pemphigus
- D. All of the above
Explanation: ***Scleroderma*** - **Extreme widening of the periodontal ligament space** is a pathognomonic radiographic finding in scleroderma (systemic sclerosis), caused by **collagen deposition** and **vascular changes** affecting the periodontal structures. - This finding is seen in up to **33% of scleroderma patients** and may be one of the earliest manifestations, often preceding other systemic symptoms. *Paget's disease* - Characterized by **cotton wool appearance** and **loss of lamina dura** on dental radiographs, not uniform periodontal ligament widening. - Shows **hypercementosis** and **root resorption** rather than the characteristic uniform thickening seen in scleroderma. *Pemphigus* - Primarily affects **oral mucosa** with **intraepithelial blistering** and **acantholysis**, without affecting periodontal ligament space. - Radiographic changes are minimal and related to **secondary infection** or **bone loss** from oral ulcerations, not periodontal ligament widening. *All of the above* - Incorrect as only **scleroderma** demonstrates the characteristic extreme periodontal ligament widening pattern. - The other conditions have distinct radiographic features that do not include uniform periodontal ligament space thickening.
Question 484: A 72-year-old man injures his right knee, which is now swollen and extremely painful to bend. X-rays of the knee rule out a fracture, and joint fluid aspiration reveals an opaque-colored fluid containing rhomboid crystals with weak-positive birefringence. Which of the following is the most appropriate next step in management?
- A. Oral prednisone
- B. Intravenous antibiotics
- C. Oral NSAIDs (Correct Answer)
- D. Acetaminophen
Explanation: **Explanation:** **1. Why Oral NSAIDs are correct:** The clinical presentation—an elderly patient with acute monoarthritis and synovial fluid showing **rhomboid-shaped, weakly positive birefringent crystals**—is diagnostic of **Pseudogout** (Calcium Pyrophosphate Deposition Disease or CPPD) [1]. For an acute attack of pseudogout involving one or two joints, the first-line treatment is **Oral NSAIDs** (e.g., Naproxen or Ibuprofen) [1]. These agents effectively reduce the intense inflammation triggered by the crystals. In patients where NSAIDs are contraindicated (e.g., renal failure or peptic ulcer disease), intra-articular corticosteroid injections are preferred. **2. Why the other options are incorrect:** * **Oral Prednisone:** While steroids are used for pseudogout, systemic (oral) steroids are generally reserved for polyarticular involvement or when NSAIDs/Colchicine are contraindicated. Intra-articular injection is preferred over oral for a single joint. * **Intravenous Antibiotics:** This would be the treatment for Septic Arthritis. While septic arthritis is a surgical emergency, the presence of rhomboid crystals confirms a crystalline etiology rather than an infectious one. * **Acetaminophen:** This provides mild analgesia but lacks the potent anti-inflammatory properties required to resolve an acute crystal-induced inflammatory flare. **3. NEET-PG High-Yield Pearls:** * **Crystal Morphology:** * **Pseudogout (CPPD):** Rhomboid/Square, Weakly Positive Birefringence (Blue when parallel to the compensator). * **Gout (MSU):** Needle-shaped, Strongly Negative Birefringence (Yellow when parallel). * **Radiology:** Look for **Chondrocalcinosis** (linear calcification of articular cartilage) on X-rays. * **Common Triggers:** Acute illness, trauma [1], or hyperparathyroidism/hypomagnesemia. * **Most Common Site:** The **Knee** is the #1 site for Pseudogout [1] (unlike the 1st MTP joint in Gout).
Question 485: Which condition is associated with Coombs positive hemolytic anemia?
- A. Thrombotic Thrombocytopenic Purpura (TTP)
- B. Polyarteritis Nodosa (PAN)
- C. Systemic Lupus Erythematosus (SLE) (Correct Answer)
- D. Hemolytic Uremic Syndrome (HUS)
Explanation: The correct answer is **Systemic Lupus Erythematosus (SLE)**. **1. Why SLE is correct:** SLE is a multisystem autoimmune disorder characterized by the production of various autoantibodies. Hematologic involvement is a hallmark of the disease. **Coombs-positive (Autoimmune) Hemolytic Anemia (AIHA)** occurs when IgG autoantibodies are directed against red blood cell (RBC) surface antigens. [1] This leads to extravascular hemolysis, primarily in the spleen. In the context of SLE, the presence of AIHA is one of the clinical criteria in the ACR/SLICC classification systems. [1] **2. Why the other options are incorrect:** * **TTP and HUS (Options A & D):** Both are forms of **Microangiopathic Hemolytic Anemia (MAHA)**. In these conditions, hemolysis is mechanical (due to RBC fragmentation in small vessels/thrombi), resulting in schistocytes on a peripheral smear. Because the mechanism is non-immune, the Direct Coombs test is characteristically **negative**. * **Polyarteritis Nodosa (Option B):** PAN is a systemic necrotizing vasculitis of medium-sized arteries. While it causes significant renal and gastrointestinal complications, it is not typically associated with autoantibody-mediated hemolysis or a positive Coombs test. **Clinical Pearls for NEET-PG:** * **Evans Syndrome:** The combination of Coombs-positive AIHA and Immune Thrombocytopenia (ITP); frequently associated with SLE. * **Drug-induced Coombs positivity:** Common culprits include Methyldopa and Penicillin. * **Complement in SLE:** AIHA in SLE is often associated with low C3 and C4 levels due to systemic complement consumption. * **MAHA vs. AIHA:** Always look for **schistocytes** (MAHA/TTP/HUS) versus **spherocytes** (AIHA/SLE) to differentiate the cause of hemolysis in exam questions. [1]
Question 486: What is the most likely diagnosis of this case?
- A. Osteomyelitis
- B. Gout (Correct Answer)
- C. Vasculitis
- D. Rheumatoid Arthritis
Explanation: ***Gout*** - Classic **punched-out erosions** with **overhanging edges** on imaging are pathognomonic for gout, particularly when involving the **first metatarsophalangeal joint**. - Presence of **tophi** (urate crystal deposits) and predilection for the **great toe** are characteristic radiological and clinical features of chronic gout. *Osteomyelitis* - Would show **bone destruction** with **sequestrum formation** and surrounding **soft tissue swelling** on imaging. - Typically associated with **systemic signs** like fever and elevated inflammatory markers, unlike the localized joint changes seen in gout. *Vasculitis* - Primarily affects **blood vessels** causing ischemic changes rather than the specific **joint erosions** seen in this case. - Would present with **systemic symptoms** like skin lesions, organ involvement, and elevated inflammatory markers rather than localized joint pathology. *Rheumatoid Arthritis* - Shows **symmetric polyarticular** involvement with **marginal erosions** and **joint space narrowing**. - Lacks the characteristic **punched-out lesions with overhanging edges** and typically spares the **distal interphalangeal joints** unlike gout's predilection for the first MTP joint.
Question 487: A 57-year-old man, previously asymptomatic and on no medications, develops a painful left big toe. It is so painful that even the weight of his sheets is excruciating. On examination, there is a swollen red toe. Which of the following medications is relatively contraindicated?
- A. indomethacin
- B. colchicine
- C. ibuprofen
- D. allopurinol (Correct Answer)
Explanation: **Explanation:** The clinical presentation of sudden, excruciating pain, redness, and swelling in the first metatarsophalangeal joint (podagra) is classic for **Acute Gouty Arthritis** [2]. **Why Allopurinol is the Correct Answer:** Allopurinol is a Xanthine Oxidase Inhibitor used for chronic urate-lowering therapy (ULT) [1]. However, it is **relatively contraindicated during an acute attack** if the patient is not already taking it. Initiating allopurinol during an acute flare causes a rapid fluctuation in serum uric acid levels, leading to the mobilization of urate crystals from tissue stores into the joint space. This "crystal shedding" can significantly worsen the existing inflammation or prolong the duration of the attack [1]. **Analysis of Incorrect Options:** * **A & C (Indomethacin and Ibuprofen):** Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the first-line treatment for acute gout [1]. They work by inhibiting prostaglandin synthesis to reduce pain and inflammation. * **B (Colchicine):** This is another first-line agent for acute gout [1]. It works by inhibiting microtubule polymerization and leukocyte chemotaxis, thereby halting the inflammatory response to urate crystals. **High-Yield Clinical Pearls for NEET-PG:** 1. **Management Strategy:** Treat the acute attack first (NSAIDs, Colchicine, or Steroids). Wait **2–4 weeks** after the symptoms have completely resolved before initiating Allopurinol. 2. **Exception:** If a patient is *already* on Allopurinol when an acute attack occurs, **do not stop it**. Continue the maintenance dose and add anti-inflammatory agents. 3. **Prophylaxis:** When starting Allopurinol, always co-prescribe low-dose Colchicine or NSAIDs for 3–6 months to prevent mobilization flares [1]. 4. **Gold Standard Diagnosis:** Arthrocentesis showing **needle-shaped, negatively birefringent** monosodium urate crystals under polarized light.
Question 488: Which of the following statements is FALSE regarding HIV-related arthritis?
- A. Cutaneous and mucosal lesions are rare.
- B. Symmetrical polyarthritis can be seen.
- C. Enthesopathy is rare.
- D. The hip is the commonest joint involved. (Correct Answer)
Explanation: Explanation: HIV-associated arthritis encompasses several patterns of joint involvement, most commonly presenting as an asymmetric oligoarthritis. 1. Why Option D is the Correct (False) Statement: In HIV-related arthritis, the lower extremity joints are most frequently affected, specifically the knees and ankles. The hip is not the most common joint involved [2]. This pattern often mimics reactive arthritis but occurs in the context of HIV infection. 2. Analysis of Incorrect Options (True Statements): * Option A: Unlike classic Reactive Arthritis (ReA), HIV-associated reactive arthritis is frequently characterized by a lack of typical extra-articular manifestations like uveitis or the classic triad [2]. Cutaneous and mucosal lesions (like keratoderma blennorrhagicum) are notably rare in HIV patients compared to HIV-negative ReA patients. * Option B: While asymmetric oligoarthritis is the hallmark, a symmetrical polyarthritis resembling Rheumatoid Arthritis (but RF negative) can occur, particularly in the early stages of HIV infection or as part of the D diffuse infiltrative lymphocytosis syndrome (DILS). * Option C: Enthesopathy (inflammation where tendons/ligaments attach to bone) is a classic feature of Spondyloarthropathies [2]. However, in the specific subset of "HIV-associated arthritis," enthesopathy is relatively rare compared to its frequency in idiopathic Psoriatic Arthritis or Ankylosing Spondylitis. Clinical Pearls for NEET-PG: * HIV-Associated Arthritis: Usually short-lived (1–6 weeks), non-erosive, and involves the knees/ankles. * Psoriatic Arthritis: Is often more severe and extensive in HIV-positive patients than in the general population [1]. * Treatment Note: NSAIDs are first-line. While methotrexate is standard for RA, it must be used with extreme caution in HIV due to further immunosuppression; HAART often improves joint symptoms.
Question 489: Which one of the following disorders is not associated with carpal tunnel syndrome?
- A. Diabetes mellitus
- B. Hypothyroidism
- C. Acromegaly
- D. Addison's disease (Correct Answer)
Explanation: Explanation: Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve as it passes through the carpal tunnel. It is typically caused by any condition that increases the volume of the contents within the tunnel or decreases the size of the tunnel itself. Why Addison’s Disease is the Correct Answer: Addison’s disease (primary adrenocortical insufficiency) is characterized by a deficiency of cortisol and aldosterone [1]. It typically leads to weight loss, dehydration, and volume depletion [1]. It does not cause the fluid retention, soft tissue hypertrophy, or deposition of metabolic byproducts necessary to compress the median nerve. Therefore, it is not associated with CTS. Analysis of Incorrect Options: * Diabetes Mellitus: This is a very common association. It causes CTS through multiple mechanisms, including increased glycosylation of collagen (leading to stiffening of the transverse carpal ligament) and a lower threshold for nerve compression due to underlying diabetic neuropathy. * Hypothyroidism: Myxedematous tissue (accumulation of glycosaminoglycans) and associated fluid retention cause increased pressure within the carpal tunnel. * Acromegaly: Excessive growth hormone leads to the overgrowth of soft tissues and bones, directly narrowing the carpal tunnel space. NEET-PG High-Yield Pearls: * Most common cause: Idiopathic. * Systemic associations (Mnemonic: ARTHRITIS): Amlyoidosis, Rheumatoid arthritis (synovitis), Trauma, Hypothyroidism, Retention of fluid (Pregnancy/CKD), Idiopathic, Tumors, Infection, Sugar (Diabetes). * Clinical Signs: Positive Phalen’s test and Tinel’s sign. * Gold Standard Diagnosis: Nerve Conduction Studies (NCS) showing delayed sensory/motor conduction across the wrist.
Question 490: Which of the following conditions is characterized by non-deforming arthritis?
- A. Syphilis
- B. Behcet's syndrome (Correct Answer)
- C. Osteoarthritis
- D. Psoriatic arthritis
Explanation: **Explanation:** **Behcet’s Syndrome (Correct Answer):** Behcet’s syndrome is a multisystem inflammatory disorder characterized by the triad of oral ulcers, genital ulcers, and uveitis. Arthritis occurs in approximately 50% of patients, typically affecting large joints (knees and ankles). The key diagnostic feature of Behcet’s arthritis is that it is **non-deforming and non-erosive**, meaning it does not cause permanent joint destruction or radiological changes, despite recurrent inflammatory episodes. **Analysis of Incorrect Options:** * **Syphilis:** Late-stage syphilis (Tabes dorsalis) is associated with **Charcot’s joint** (neuropathic arthropathy). This is a severely deforming, destructive arthropathy resulting from the loss of pain sensation and proprioception. * **Osteoarthritis (OA):** OA is a degenerative joint disease characterized by the progressive loss of articular cartilage, subchondral sclerosis, and the formation of osteophytes. It is inherently **deforming**, leading to conditions like Heberden’s and Bouchard’s nodes. * **Psoriatic Arthritis (PsA):** PsA is an inflammatory seronegative spondyloarthropathy [2]. It is often **highly erosive and deforming**, classically presenting with "pencil-in-cup" deformities on X-ray and *arthritis mutilans* in severe cases [1]. **NEET-PG Clinical Pearls:** * **Non-deforming Arthritis "Club":** Besides Behcet’s, other classic conditions with non-deforming arthritis include **SLE** (though Jaccoud’s arthropathy can show reversible deformity), **Rheumatic Fever**, and **Henoch-Schönlein Purpura (HSP)**. * **Behcet’s Hallmark:** Look for the **Pathergy Test** (development of a papule/pustule 24-48 hours after a sterile needle prick), which is highly specific for this syndrome. * **HLA Association:** Behcet’s is strongly associated with **HLA-B51**.
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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