Rheumatology and Immunology Practice Questions

Q: A 30-year-old male presents with numbness of both lower limbs and right upper limb. Examination reveals pulse 88/min and BP 160/110 mmHg. He also has digital gangrene involving the right 2nd and 3rd fingers. Urine routine examination is unremarkable. Microscopic examination shows RBCs. Hemogram and serum biochemistry are within normal limits. What is the most probable diagnosis?

Polyarteritis nodosa. **Explanation:** The clinical presentation of **Polyarteritis Nodosa (PAN)** is characterized by a "multi-system involvement" [1] that typically spares the lungs. This case highlights the classic triad of PAN: **Mononeuritis multiplex** (asymmetric numbness/nerve involvement), **Renovascular hypertension** (BP 160/110 mmHg), and **Cutaneous ischemia/gangrene**. 1. **Why PAN is correct:** PAN is a necrotizing vasculitis of medium-sized arteries [1]. It frequently involves the renal arteries (causing hypertension due to activation of the RAAS) and the vasa nervorum (causing mononeuritis multiplex). Crucially, PAN **spares the glomeruli**; therefore, while it causes renal artery narrowing or microaneurysms (leading to hematuria), it does **not** typically cause glomerulonephritis (no RBC casts or significant proteinuria), which matches the "unremarkable" urine routine mentioned. 2. **Why other options are incorrect:** * **SLE:** Usually presents with malar rash, arthritis, and significant proteinuria/casts (lupus nephritis), which are absent here. * **Malignant Hypertension:** While it explains high BP and some neurological symptoms, it does not explain asymmetric mononeuritis or digital gangrene in a 30-year-old without a primary cause. * **Churg-Strauss (EGPA):** This is a small-vessel vasculitis characterized by asthma, eosinophilia, and pulmonary infiltrates [2], none of which are present in this patient. **High-Yield Clinical Pearls for NEET-PG:** * **PAN Association:** Strongly associated with **Hepatitis B** (HBV) surface antigenemia (10–30% of cases). * **Imaging Gold Standard:** Digital Subtraction Angiography (DSA) showing **"string of beads"** appearance (microaneurysms). * **Key Negative:** PAN is **ANCA-negative** and characteristically **spares the lungs**. * **Treatment:** Corticosteroids and Cyclophosphamide; treat HBV if present [2].

Q: A 40-year-old female presents with a history of fever, weight loss, and polyarthralgia. Given the radiological findings, what is the most likely diagnosis?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Symmetric joint space narrowing** and **marginal erosions** at MCP/PIP joints with **periarticular osteopenia** are characteristic radiological findings of RA in a 40-year-old female. - The combination of **fever**, **weight loss**, and **polyarthralgia** reflects the **systemic inflammatory nature** of rheumatoid arthritis. *Osteoarthritis* - Radiological findings would show **osteophytes** and **joint space narrowing** primarily affecting **DIP joints**, not the pattern described. - Lacks **systemic symptoms** like fever and weight loss, typically presenting with **mechanical pain** in older patients. *Gout* - Characterized by **asymmetric punched-out erosions** with **overhanging edges** and possible **tophi**, not symmetric marginal erosions. - Typically affects the **first metatarsophalangeal joint** initially and lacks the systemic inflammatory features described. *Psoriatic arthritis* - Shows distinctive **pencil-in-cup deformity** and **asymmetric joint involvement**, often affecting **DIP joints** with **psoriatic skin lesions**. - Lacks the **symmetric pattern** and **periarticular osteopenia** characteristic of the described radiological findings.

Q: Strawberry gingivitis is classically seen in which of the following conditions?

Granulomatosis with polyangiitis. **Explanation:** **Granulomatosis with Polyangiitis (GPA)**, formerly known as Wegener’s Granulomatosis, is a small-vessel vasculitis characterized by a triad of upper respiratory tract, lower respiratory tract, and renal involvement. **Strawberry gingivitis** is a pathognomonic clinical sign of GPA. It manifests as erythematous, granular, and friable swelling of the gingiva with petechial hemorrhages, resembling the surface of a strawberry. This occurs due to necrotizing granulomatous inflammation of the oral mucosa. **Analysis of Incorrect Options:** * **Goodpasture Syndrome:** This is an anti-GBM antibody disease characterized by the duo of pulmonary hemorrhage and glomerulonephritis. It does not typically involve the upper airway or oral mucosa. * **Classic Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis associated with Hepatitis B. It involves the skin (livedo reticularis), nerves (mononeuritis multiplex), and kidneys (microaneurysms), but characteristically **spares the lungs** and does not cause strawberry gingivitis. * **Kawasaki Syndrome:** While it presents with oral findings like a "strawberry tongue" (inflamed papillae) and cracked red lips, it does not cause "strawberry gingivitis" (gingival hyperplasia/petechiae). **NEET-PG High-Yield Pearls:** * **Serology:** GPA is strongly associated with **c-ANCA (PR3-ANCA)**. * **Classic Triad:** Sinusitis (saddle nose deformity), Hemoptysis (cavitary lesions), and Hematuria (RPGN). * **Histology:** Look for "Geographic necrosis" and poorly formed granulomas. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab).

Q: Pseudolymphoma is a known association with which of the following conditions?

Sjogren's syndrome. **Explanation:** **Sjogren’s syndrome (SS)** is the correct answer because it is characterized by a chronic, progressive infiltration of exocrine glands by lymphocytes (primarily B and T cells). In some patients, this lymphocytic proliferation becomes so intense that it mimics a malignant lymphoma histologically and clinically, a condition termed **Pseudolymphoma**. * **Mechanism:** In SS, there is chronic B-cell hyperactivity. Pseudolymphoma represents an intermediate stage in the multistep process of lymphoproliferation, situated between benign inflammatory infiltration and frank **B-cell Non-Hodgkin Lymphoma (NHL)**. Patients with SS have a **44-fold increased risk** of developing lymphoma (most commonly MALToma). **Analysis of Incorrect Options:** * **B. Systemic Lupus Erythematosus (SLE):** While SLE is associated with lymphadenopathy and an increased risk of malignancy, "Pseudolymphoma" is not a classic or defining association. * **C. Mixed Connective Tissue Disease (MCTD):** MCTD features overlapping symptoms of SLE, systemic sclerosis, and myositis, commonly presenting with synovitis and hand edema [1]. However, it does not typically present with the specific lymphoproliferative "pseudolymphoma" seen in Sjogren's. * **D. Behcet’s Syndrome:** This is a systemic vasculitis characterized by oral/genital ulcers and uveitis; it is not associated with pseudolymphomatous proliferation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common lymphoma in Sjogren’s:** MALT lymphoma (Mucosa-Associated Lymphoid Tissue), often involving the parotid gland. * **Predictors of Lymphoma in SS:** Persistent parotid swelling, purpura, leukopenia, low C4 levels, and mixed cryoglobulinemia. * **Schirmer’s Test:** Used for diagnosis (positive if <5 mm wetting in 5 minutes). * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are the hallmark serological markers.

Q: The most common pulmonary manifestation of Systemic Lupus Erythematosus (SLE) is:

Pleuritis. **Explanation:** Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease that frequently involves the respiratory system. **Pleuritis** is the most common pulmonary manifestation [1], occurring in approximately 45% to 60% of patients during the course of their illness. It typically presents as pleuritic chest pain with or without a pleural rub. **Analysis of Options:** * **A. Pleuritis (Correct):** It is the hallmark pulmonary feature of SLE. It can occur as an isolated finding or as part of polyserositis (involving the pericardium or peritoneum) [1]. * **B. Pleural effusion:** While common, it is usually a consequence of pleuritis. Effusions in SLE are typically exudative, bilateral, and small-to-moderate in size [1]. * **C. Pulmonary hypertension:** This is a serious but less common complication (approx. 5–10%), often associated with Raynaud’s phenomenon or antiphospholipid syndrome [1]. * **D. Interstitial lung disease (ILD):** Unlike Systemic Sclerosis (Scleroderma), where ILD is a primary feature [1], chronic ILD is relatively rare in SLE (occurring in <10% of cases). **High-Yield Clinical Pearls for NEET-PG:** * **Shrinking Lung Syndrome:** A rare but characteristic SLE manifestation characterized by progressive dyspnea, reduced lung volumes, and diaphragmatic dysfunction (elevated hemidiaphragms) [1]. * **Acute Lupus Pneumonitis:** A life-threatening presentation involving fever, cough, and pulmonary infiltrates; it requires differentiation from infection [1]. * **Pleural Fluid Profile:** In SLE, pleural fluid typically shows a low glucose level (though not as low as in Rheumatoid Arthritis) and high ANA titers (often >1:160). * **Comparison:** While **Pleuritis** is most common in SLE, **ILD** is the most common pulmonary manifestation in Systemic Sclerosis and Rheumatoid Arthritis [1].

Question 1

A 30-year-old male presents with numbness of both lower limbs and right upper limb. Examination reveals pulse 88/min and BP 160/110 mmHg. He also has digital gangrene involving the right 2nd and 3rd fingers. Urine routine examination is unremarkable. Microscopic examination shows RBCs. Hemogram and serum biochemistry are within normal limits. What is the most probable diagnosis?

Accepted Answer

Polyarteritis nodosa

Answer

Systemic lupus erythematosus

Answer

Malignant hypertension

Answer

Churg-Strauss syndrome

Question 2

Which of the following is NOT a small vessel vasculitis?

Accepted Answer

Takayasu's arteritis

Answer

Wegener's granulomatosis

Answer

Churg Strauss Syndrome

Answer

Microscopic polyangitis

Question 3

A 40-year-old female presents with a history of fever, weight loss, and polyarthralgia. Given the radiological findings, what is the most likely diagnosis?

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Gout

Answer

Psoriatic arthritis

Question 4

Strawberry gingivitis is classically seen in which of the following conditions?

Accepted Answer

Granulomatosis with polyangiitis

Answer

Goodpasture syndrome

Answer

Classic polyarteritis nodosa

Answer

Kawasaki syndrome

Question 5

Pseudolymphoma is a known association with which of the following conditions?

Accepted Answer

Sjogren's syndrome

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Mixed connective tissue disease

Answer

Behcet's syndrome

Question 6

In idiopathic polymyositis, which of the following is typically NOT seen?

Accepted Answer

Cutaneous manifestations are present

Answer

Ocular muscles are not involved

Answer

Pharyngeal muscles are involved

Answer

Proximal limb muscles are invariably involved

Question 7

The most common pulmonary manifestation of Systemic Lupus Erythematosus (SLE) is:

Accepted Answer

Pleuritis

Answer

Pleural effusion

Answer

Pulmonary hypertension

Answer

Interstitial lung disease (ILD)

Question 8

What tests should be performed before initiating infliximab therapy in a 60-year-old female patient with rheumatoid arthritis?

Accepted Answer

Ophthalmological examination

Answer

Liver Function Tests (LFT)

Answer

Purified Protein Derivative (PPD) skin test

Answer

Pulmonary Function Tests (PFT)

Question 9

Myopathy is seen in all except?

Accepted Answer

X-linked hypophosphatemic rickets

Answer

Oncogenic osteomalacia

Answer

Nutritional osteomalacia

Answer

Cushing syndrome

Question 10

A 65-year-old male develops sudden onset of severe knee pain, redness, swelling, and tenderness. He has a history of diabetes mellitus and cardiomyopathy. An X-ray of the knee shows linear calcification. Which of the following investigations is best for making a definitive diagnosis?

Accepted Answer

Arthrocentesis and identification of positively birefringent rhomboid crystals

Answer

Serum uric acid

Answer

Serum calcium

Answer

Rheumatoid factor

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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