Rheumatology and Immunology — MCQs
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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?
Which of the following is NOT a small vessel vasculitis?
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?
Strawberry gingivitis is classically seen in which of the following conditions?
Pseudolymphoma is a known association with which of the following conditions?
In idiopathic polymyositis, which of the following is typically NOT seen?
The most common pulmonary manifestation of Systemic Lupus Erythematosus (SLE) is:
What tests should be performed before initiating infliximab therapy in a 60-year-old female patient with rheumatoid arthritis?
Myopathy is seen in all except?
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?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 511: 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?
- A. Systemic lupus erythematosus
- B. Polyarteritis nodosa (Correct Answer)
- C. Malignant hypertension
- D. Churg-Strauss syndrome
Explanation: **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].
Question 512: Which of the following is NOT a small vessel vasculitis?
- A. Wegener's granulomatosis
- B. Churg Strauss Syndrome
- C. Takayasu's arteritis (Correct Answer)
- D. Microscopic polyangitis
Explanation: This question tests your knowledge of the **Chapel Hill Consensus Conference (CHCC)** classification of vasculitis, which categorizes these disorders based on the caliber of the blood vessels primarily affected [1]. ### **Explanation of the Correct Answer** **C. Takayasu’s Arteritis** is the correct answer because it is a **Large Vessel Vasculitis (LVV)**. It primarily affects the aorta and its major branches. It is often referred to as "Pulseless Disease" because the inflammatory narrowing of the vessels leads to diminished peripheral pulses, typically in young females. The other major LVV is Giant Cell (Temporal) Arteritis. ### **Analysis of Incorrect Options** The remaining options are all classified as **Small Vessel Vasculitis (SVV)**, specifically those associated with **ANCA (Antineutrophil Cytoplasmic Antibodies)**: * **A. Wegener’s Granulomatosis (now Granulomatosis with Polyangiitis - GPA):** A small vessel vasculitis characterized by granulomatous inflammation of the respiratory tract and glomerulonephritis. It is strongly associated with **c-ANCA (PR3)**. * **B. Churg-Strauss Syndrome (now Eosinophilic Granulomatosis with Polyangiitis - EGPA):** A small vessel vasculitis characterized by asthma, peripheral eosinophilia, and necrotizing vasculitis. Associated with **p-ANCA (MPO)**. * **D. Microscopic Polyangiitis (MPA):** A necrotizing small vessel vasculitis without granulomatous inflammation. It commonly involves the kidneys (pauci-immune GN) and lungs. Associated with **p-ANCA (MPO)**. ### **High-Yield Clinical Pearls for NEET-PG** * **Large Vessel:** Takayasu’s, Giant Cell Arteritis. * **Medium Vessel:** Polyarteritis Nodosa (PAN), Kawasaki Disease. * **Small Vessel (ANCA +ve):** GPA, EGPA, MPA. * **Small Vessel (Immune Complex):** Henoch-Schönlein Purpura (IgA vasculitis), Cryoglobulinemic vasculitis, Anti-GBM disease. * **Takayasu's Fact:** Most common in females <40 years; involves the aortic arch; diagnosed via angiography showing "string of pearls" or narrowing.
Question 513: 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?
- A. Osteoarthritis
- B. Rheumatoid arthritis (Correct Answer)
- C. Gout
- D. Psoriatic arthritis
Explanation: ***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.
Question 514: Strawberry gingivitis is classically seen in which of the following conditions?
- A. Goodpasture syndrome
- B. Classic polyarteritis nodosa
- C. Granulomatosis with polyangiitis (Correct Answer)
- D. Kawasaki syndrome
Explanation: **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).
Question 515: Pseudolymphoma is a known association with which of the following conditions?
- A. Sjogren's syndrome (Correct Answer)
- B. Systemic Lupus Erythematosus (SLE)
- C. Mixed connective tissue disease
- D. Behcet's syndrome
Explanation: **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.
Question 516: In idiopathic polymyositis, which of the following is typically NOT seen?
- A. Ocular muscles are not involved
- B. Pharyngeal muscles are involved
- C. Cutaneous manifestations are present (Correct Answer)
- D. Proximal limb muscles are invariably involved
Explanation: **Explanation:** The core of this question lies in the clinical distinction between **Polymyositis (PM)** and **Dermatomyositis (DM)**. While both are inflammatory myopathies characterized by proximal muscle weakness, their clinical presentations differ regarding skin involvement. **1. Why "Cutaneous manifestations are present" is the correct answer:** In **Idiopathic Polymyositis**, cutaneous manifestations are characteristically **absent**. If a patient presents with the classic rashes—such as the **Heliotrope rash** (periorbital violaceous discoloration) [2] or **Gottron’s papules** (erythematous scaly eruptions over the knuckles)—the diagnosis shifts to **Dermatomyositis** [1]. Therefore, stating that cutaneous manifestations are present in PM is incorrect. **2. Analysis of Incorrect Options:** * **A. Ocular muscles are not involved:** This is a **true** statement [1]. Inflammatory myopathies (PM/DM) typically spare the extraocular and facial muscles. Involvement of these muscles should raise suspicion of Myasthenia Gravis or Mitochondrial Myopathies. * **B. Pharyngeal muscles are involved:** This is **true**. Involvement of the striated muscles of the upper esophagus and pharynx is common, leading to dysphagia and an increased risk of aspiration pneumonia [1]. * **C. Proximal limb muscles are invariably involved:** This is **true**. Symmetric proximal muscle weakness (shoulder and pelvic girdle) is the hallmark of PM [1]. Patients typically struggle with overhead activities or rising from a chair. **High-Yield Clinical Pearls for NEET-PG:** * **Enzymes:** Elevated **CPK (Creatine Phosphokinase)** is the most sensitive initial lab marker [2]. * **Antibodies:** **Anti-Jo-1** is the most common myositis-specific antibody and is strongly associated with **Antisynthetase Syndrome** (interstitial lung disease, Raynaud's, and "mechanic's hands") [1]. * **Diagnosis:** The gold standard for definitive diagnosis is a **Muscle Biopsy** (showing endomysial inflammation with CD8+ T-cells in PM). * **Malignancy:** Both PM and DM (especially DM) are associated with an increased risk of occult visceral malignancies [2].
Question 517: The most common pulmonary manifestation of Systemic Lupus Erythematosus (SLE) is:
- A. Pleuritis (Correct Answer)
- B. Pleural effusion
- C. Pulmonary hypertension
- D. Interstitial lung disease (ILD)
Explanation: **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 518: What tests should be performed before initiating infliximab therapy in a 60-year-old female patient with rheumatoid arthritis?
- A. Liver Function Tests (LFT)
- B. Purified Protein Derivative (PPD) skin test
- C. Pulmonary Function Tests (PFT)
- D. Ophthalmological examination (Correct Answer)
Explanation: The question asks for the necessary screening before initiating **Infliximab**, a chimeric monoclonal antibody against Tumor Necrosis Factor-alpha (TNF-α). [1] **Why the Correct Answer is D (Ophthalmological examination):** While TNF-α inhibitors are generally used to treat certain types of uveitis, they can paradoxically trigger or exacerbate **demyelinating diseases** (like Multiple Sclerosis) and, in some cases, cause **optic neuritis**. In a 60-year-old patient, a baseline ophthalmological exam is vital to rule out pre-existing ocular pathologies or subclinical optic nerve involvement, as TNF inhibitors are contraindicated in patients with active demyelinating disorders. **Analysis of Incorrect Options:** * **A. Liver Function Tests (LFT):** While some biologics require monitoring, LFTs are more critical for **Methotrexate** or Leflunomide rather than a specific pre-requisite for Infliximab. [2] * **B. Purified Protein Derivative (PPD):** This is a **trick option**. Screening for latent Tuberculosis (TB) is mandatory before starting any TNF inhibitor. However, the PPD test is often unreliable in RA patients due to anergy. The **Interferon-Gamma Release Assay (IGRA)** is now the preferred screening tool. * **C. Pulmonary Function Tests (PFT):** These are typically indicated before starting **Methotrexate** (due to risk of pneumonitis) or in patients with suspected Interstitial Lung Disease (ILD), but not a routine requirement for Infliximab. [2] **High-Yield Clinical Pearls for NEET-PG:** * **TNF-α Inhibitors (Infliximab, Adalimumab, Etanercept):** Must screen for **Latent TB** (Chest X-ray + IGRA) and **Hepatitis B** before initiation. * **Contraindications:** Avoid TNF inhibitors in patients with **NYHA Class III/IV Heart Failure** (can worsen mortality) and **Demyelinating diseases**. * **Infusion Reactions:** Infliximab is "chimeric" (mouse/human), making it more likely to cause infusion reactions compared to fully human antibodies like Adalimumab. [1]
Question 519: Myopathy is seen in all except?
- A. X-linked hypophosphatemic rickets (Correct Answer)
- B. Oncogenic osteomalacia
- C. Nutritional osteomalacia
- D. Cushing syndrome
Explanation: The core concept behind this question is the relationship between **phosphate levels, Vitamin D metabolism, and muscle function**. Proximal myopathy is a classic feature of most forms of osteomalacia, but it is notably **absent** in X-linked hypophosphatemic rickets (XLH). [1] **1. Why X-linked Hypophosphatemic Rickets (XLH) is the correct answer:** XLH is caused by a mutation in the *PHEX* gene, leading to increased levels of **FGF-23**. While FGF-23 causes renal phosphate wasting (hypophosphatemia) [2], it also **suppresses** the production of 1,25-dihydroxyvitamin D (Calcitriol). Interestingly, despite profound hypophosphatemia, patients with XLH **do not develop myopathy**. The exact reason is debated, but it is believed that the specific metabolic defect in XLH spares the intracellular muscle phosphokinase pathways. **2. Analysis of Incorrect Options:** * **Nutritional Osteomalacia:** Severe Vitamin D deficiency leads to secondary hyperparathyroidism and hypophosphatemia. Low levels of Vitamin D and phosphate directly impair muscle mitochondrial function, leading to significant proximal muscle weakness (waddling gait). [1] * **Oncogenic Osteomalacia:** Similar to XLH, this is mediated by FGF-23 (secreted by mesenchymal tumors). However, unlike the congenital XLH, the acquired and rapid drop in phosphate in oncogenic osteomalacia is frequently associated with severe muscle weakness. * **Cushing Syndrome:** Excess glucocorticoids cause **Steroid Myopathy** through protein catabolism and induction of muscle atrophy (specifically Type IIb fibers). This is a classic cause of proximal myopathy. **Clinical Pearls for NEET-PG:** * **The "Rule of Absence":** Myopathy is absent in XLH but present in almost all other forms of rickets/osteomalacia. * **FGF-23:** Remember it as a "Phosphatonin"—it lowers phosphate by decreasing renal reabsorption and decreasing Vitamin D activation. [2] * **Proximal Myopathy Differential:** Always consider Hypokalemia, Hypercortisolism (Cushing's), Hyperthyroidism, and Osteomalacia.
Question 520: 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?
- A. Serum uric acid
- B. Serum calcium
- C. Arthrocentesis and identification of positively birefringent rhomboid crystals (Correct Answer)
- D. Rheumatoid factor
Explanation: The clinical presentation of sudden onset monoarthritis (pain, swelling, redness) in an elderly patient, combined with **linear calcification** on X-ray (**Chondrocalcinosis**), is classic for **Calcium Pyrophosphate Deposition (CPPD) disease**, formerly known as Pseudogout [1]. **1. Why Option C is Correct:** The gold standard for a definitive diagnosis of any crystal-induced arthropathy is **Arthrocentesis** (joint fluid aspiration). Under polarized light microscopy, CPPD is identified by the presence of **rhomboid-shaped crystals** that exhibit **weak positive birefringence**. This distinguishes it from Gout, which features needle-shaped, negatively birefringent crystals. **2. Why Other Options are Incorrect:** * **A. Serum uric acid:** This is used to evaluate Gout. However, serum levels can be normal during an acute attack, and it would not explain the chondrocalcinosis seen on X-ray. * **B. Serum calcium:** While hyperparathyroidism (causing hypercalcemia) is a risk factor for CPPD, measuring serum calcium does not confirm the diagnosis of the acute joint inflammation itself. * **D. Rheumatoid factor:** This is a screening tool for Rheumatoid Arthritis, which typically presents as a chronic, symmetric polyarthritis [2], not an acute monoarthritis with linear calcification. **3. Clinical Pearls for NEET-PG:** * **The "3 Cs" of Pseudogout:** **C**alcium pyrophosphate, **C**hondrocalcinosis, and **C**onvex (rhomboid) crystals. * **Associated Conditions:** Always screen for the "4 Hs": **H**yperparathyroidism, **H**emochromatosis [3] (suggested by the patient's cardiomyopathy and diabetes/bronze diabetes), **H**ypomagnesemia, and **H**ypothyroidism. * **Radiology:** The most common site for chondrocalcinosis is the **knee** (meniscus), followed by the triangular cartilage of the wrist [1].
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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