Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 561: Which condition characteristically involves the lungs?

A. Churg-Strauss syndrome (Correct Answer)
B. Henoch-Schönlein purpura (HSP)
C. Polyarteritis nodosa (PAN)
D. Idiopathic thrombocytopenic purpura (ITP)

Explanation: **Explanation:** The correct answer is **Churg-Strauss syndrome** (now known as Eosinophilic Granulomatosis with Polyangiitis or EGPA). **1. Why Churg-Strauss Syndrome is correct:** EGPA is a small-vessel necrotizing vasculitis characterized by three hallmark features: **asthma, peripheral eosinophilia, and extravascular granulomas.** [1] Lung involvement is the defining feature of this condition, often presenting as severe, corticosteroid-dependent asthma or pulmonary infiltrates. [2] It is strongly associated with **p-ANCA (anti-MPO)** positivity. [2] **2. Why the other options are incorrect:** * **Polyarteritis nodosa (PAN):** This is a medium-vessel vasculitis. A classic "high-yield" rule for exams is that **PAN characteristically spares the lungs.** [1] It primarily affects the renal and visceral arteries, often associated with Hepatitis B. * **Henoch-Schönlein purpura (HSP):** This is an IgA-mediated small-vessel vasculitis. [2] It typically presents with a tetrad of palpable purpura (lower extremities), arthralgia, abdominal pain, and renal disease (IgA nephropathy). Lung involvement is extremely rare. * **Idiopathic thrombocytopenic purpura (ITP):** This is a hematologic disorder characterized by isolated thrombocytopenia due to anti-platelet antibodies. It causes bleeding manifestations (petechiae, mucosal bleed) but does not involve primary pulmonary pathology or vasculitis. **Clinical Pearls for NEET-PG:** * **ANCA Associations:** c-ANCA (PR3) = Wegener’s (GPA); p-ANCA (MPO) = Churg-Strauss (EGPA) and Microscopic Polyangiitis (MPA). [2] * **Lung Involvement in Vasculitis:** Both GPA and MPA involve the lungs, but EGPA is unique due to the presence of **asthma and eosinophilia.** [1] * **PAN Rule:** If a question describes systemic vasculitis but explicitly mentions the **absence of pulmonary symptoms**, think Polyarteritis Nodosa.

Question 562: Polyarticular rheumatoid arthritis is diagnosed when more than how many joints are involved?

A. One
B. Two
C. Four
D. Five (Correct Answer)

Explanation: The classification of joint involvement in inflammatory arthritis is based on the number of joints affected. This categorization is crucial for narrowing down differential diagnoses in rheumatology. 1. **Why Option D is Correct:** In clinical practice and according to standard rheumatological definitions (including the **ACR/EULAR 2010 Classification Criteria for Rheumatoid Arthritis**), **Polyarthritis** is defined as the involvement of **5 or more joints**. Rheumatoid Arthritis (RA) typically presents as a symmetric polyarthritis, frequently involving the small joints of the hands and feet [1]. 2. **Why Other Options are Incorrect:** * **Option A (One):** Involvement of a single joint is termed **Monoarthritis** [3]. Common causes include gout, septic arthritis, or trauma. * **Option B & C (Two to Four):** Involvement of 2 to 4 joints is termed **Oligoarthritis** (or Pauciarthritis). This pattern is commonly seen in Spondyloarthropathies (like Psoriatic Arthritis or Reactive Arthritis) and certain subtypes of Juvenile Idiopathic Arthritis (JIA). **High-Yield Clinical Pearls for NEET-PG:** * **ACR/EULAR 2010 Criteria:** Scoring for joint involvement increases with the number of joints; 1 large joint (0 points), 2–10 large joints (1 point), 1–3 small joints (2 points), 4–10 small joints (3 points), and **>10 joints (5 points)** [2]. * **Joint Sparing:** RA characteristically **spares the Distal Interphalangeal (DIP) joints** and the thoracolumbar spine (except C1-C2). * **Symmetry:** RA is typically symmetric, whereas seronegative spondyloarthropathies are often asymmetric oligoarthritis [1]. * **Small Joints:** The most common joints involved in RA are the MCP, PIP, and MTP joints.

Question 563: Which of the following joint findings is most suggestive of an inflammatory cause of joint pain, rather than osteoarthritis?

A. Painful range of motion
B. Crepitus
C. Bony articular enlargement
D. Swelling and warmth (Correct Answer)

Explanation: ### Explanation The primary clinical challenge in rheumatology is distinguishing between **inflammatory arthritis** (e.g., Rheumatoid Arthritis) and **non-inflammatory/degenerative joint disease** (e.g., Osteoarthritis). **Why "Swelling and Warmth" is correct:** Inflammatory arthritis is characterized by the "cardinal signs of inflammation" resulting from synovitis. **Warmth, erythema, and soft-tissue swelling** (effusion or synovial thickening) indicate active immunological activity and increased vascularity. In contrast, Osteoarthritis (OA) is a degenerative process where these signs are typically absent or very minimal. **Analysis of Incorrect Options:** * **A. Painful range of motion:** This is a non-specific finding. Both inflammatory and degenerative conditions cause pain during movement due to either synovial irritation or mechanical friction. * **B. Crepitus:** This is a classic feature of **Osteoarthritis**. It represents the "grating" sensation or sound produced by friction between bone and cartilage or fractured cartilage surfaces. * **C. Bony articular enlargement:** This is characteristic of **Osteoarthritis**, caused by the formation of **osteophytes** (e.g., Heberden’s and Bouchard’s nodes) [1]. In inflammatory arthritis, swelling is typically "boggy" or soft (synovial) rather than bony. **NEET-PG High-Yield Pearls:** * **Morning Stiffness:** If it lasts **>1 hour**, it suggests inflammatory arthritis; if **<30 minutes**, it suggests OA. * **Gell and Coombs Classification:** RA is primarily a Type IV (Delayed) hypersensitivity, though Type III (Immune complex) also plays a role. * **Joint Involvement:** OA typically involves the DIP joints [2]; RA characteristically **spares the DIP joints** and involves the MCP and PIP joints [3]. * **Synovial Fluid:** Inflammatory fluid is translucent/opaque with WBC counts typically between **2,000–50,000 cells/mm³**.

Question 564: Raynaud's phenomenon is seen in which of the following conditions?

A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
B. Rheumatic fever
C. Hypertension
D. Diabetes mellitus

Explanation: **Explanation:** **Raynaud’s Phenomenon (RP)** is a clinical condition characterized by episodic digital ischemia, typically manifesting as a triphasic color change (White/Pallor → Blue/Cyanosis → Red/Hyperemia) in response to cold or stress. 1. **Why SLE is correct:** Raynaud’s phenomenon is a common feature of various **Connective Tissue Diseases (CTDs)** [2]. In **Systemic Lupus Erythematosus (SLE)**, RP occurs in approximately 30% of patients. It is caused by exaggerated vasospasm of the digital arteries and arterioles, often exacerbated by underlying vasculitis or endothelial dysfunction associated with the autoimmune process [1]. 2. **Why other options are incorrect:** * **Rheumatic Fever:** This is an inflammatory disease following a Group A Streptococcal infection. While it involves joints (migratory polyarthritis) and the heart, it does not typically involve the peripheral vasospasm seen in RP. * **Hypertension:** This involves systemic elevation of blood pressure and chronic vascular remodeling but does not present with episodic, cold-induced digital vasospasm. * **Diabetes Mellitus:** While DM causes peripheral neuropathy and microvascular damage (diabetic angiopathy), it does not cause the classic reversible vasospastic episodes of Raynaud's. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Raynaud’s (Raynaud’s Disease):** Most common; occurs in isolation without an underlying disease. Usually symmetrical with normal nailfold capillaries. * **Secondary Raynaud’s (Raynaud’s Phenomenon):** Associated with underlying conditions [1]. The strongest association is with **Systemic Sclerosis (Scleroderma)**, where it occurs in >95% of patients and is often the presenting symptom [1]. * **CREST Syndrome:** Raynaud’s is the 'R' in this variant of limited cutaneous systemic sclerosis. * **Drug-induced RP:** Beta-blockers, ergotamine, and chemotherapy agents (bleomycin) are known triggers. * **Treatment:** Calcium Channel Blockers (e.g., **Nifedipine**) are the first-line medical therapy.

Question 565: Which of the following is NOT true about scleroderma renal crisis?

A. Accelerated hypertension
B. Onion skinning of renal vessels
C. Anti-centromere antibody positivity is a predictor of skin and lung involvement (Correct Answer)
D. ACE inhibitors reduce mortality rate

Explanation: **Explanation:** Scleroderma Renal Crisis (SRC) is a life-threatening complication occurring in approximately 10–15% of patients with **diffuse cutaneous systemic sclerosis (dcSSc)** [1]. **Why Option C is the correct answer (False statement):** The primary antibody associated with an increased risk of SRC is **Anti-RNA Polymerase III**, not anti-centromere. **Anti-centromere antibodies** are typically associated with **Limited cutaneous systemic sclerosis (lcSSc)** and CREST syndrome, which generally carry a lower risk of renal involvement but a higher risk of pulmonary arterial hypertension. **Analysis of Incorrect Options (True statements about SRC):** * **A. Accelerated Hypertension:** SRC typically presents with sudden-onset malignant hypertension (often >150/90 mmHg) and flash pulmonary edema. Note: A "normotensive" variant exists but is less common. * **B. Onion skinning of renal vessels:** Histopathology reveals characteristic proliferative endarteritis [1]. This "onion-skin" appearance is due to concentric proliferation of intimal cells, leading to vascular lumen narrowing and ischemia [1]. * **D. ACE inhibitors (ACEi):** These are the **gold standard** treatment. Before ACEi, SRC was almost universally fatal. They work by reversing the hyper-reninemia driving the crisis. They should be started immediately, even if there is a transient rise in creatinine. **High-Yield Clinical Pearls for NEET-PG:** 1. **Risk Factor:** Use of high-dose **Corticosteroids** (>15mg prednisolone/day) is a major trigger for SRC. 2. **Microangiopathic Hemolytic Anemia (MAHA):** SRC often presents with schistocytes on peripheral smear and thrombocytopenia, mimicking TTP/HUS. 3. **Prognosis:** Despite treatment, about 25% of patients may still require permanent dialysis. 4. **Drug of Choice:** Captopril (short-acting ACEi) is often preferred for rapid titration in acute settings.

Question 566: ASO titre is diagnostic in?

A. SBE (Subacute bacterial endocarditis)
B. Rheumatoid arthritis
C. Infective endocarditis
D. Acute rheumatic fever (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Acute Rheumatic Fever** **Why it is correct:** Anti-Streptolysin O (ASO) is an antibody directed against **Streptolysin O**, an exotoxin produced by Group A Beta-hemolytic *Streptococcus* (GABHS). According to the **Revised Jones Criteria**, evidence of a preceding streptococcal infection is mandatory for the diagnosis of Acute Rheumatic Fever (ARF) [1]. An elevated or rising ASO titre (typically >200 IU/mL in adults or >333 IU/mL in children) serves as this essential immunologic evidence. It peaks 3–5 weeks after the initial sore throat, coinciding with the onset of ARF symptoms. **Why the other options are incorrect:** * **A & C (SBE/Infective Endocarditis):** These are typically caused by *Staphylococcus aureus*, *Viridans streptococci*, or *Enterococci* [2]. ASO is specific to Group A *Streptococcus* and does not play a diagnostic role here. Diagnosis relies on **Duke’s Criteria** (Blood cultures and Echocardiography). * **B (Rheumatoid Arthritis):** This is a chronic autoimmune inflammatory disorder. Diagnosis is based on clinical features, **Rheumatoid Factor (RF)**, and **Anti-CCP** antibodies. ASO titres are unrelated to its pathogenesis [3]. **High-Yield Clinical Pearls for NEET-PG:** * **Most sensitive test** for preceding GABHS infection in ARF is the **Antistreptococcal antibody test** (ASO is the most common, but Anti-DNase B is more sensitive for skin infections/pyoderma) [1]. * ASO titres do **not** correlate with the severity of the disease or the risk of developing carditis. * In cases of **Post-Streptococcal Glomerulonephritis (PSGN)** following a skin infection, the ASO titre may be low or absent; **Anti-DNase B** is the preferred marker there. * **Jones Criteria Mnemonic (Major):** **J**oints (Migratory Polyarthritis), **O** (Carditis - looks like a heart), **N**odules (Subcutaneous), **E**rythema Marginatum, **S**ydenham’s Chorea.

Question 567: A young male presents with painful ulcers on the mouth and glans penis, blurred vision, and a history of recurrent epididymitis. What is the most probable diagnosis?

A. Behcet syndrome (Correct Answer)
B. Oculocutaneous aphthous ulcer syndrome
C. Fabry's disease
D. Epidermolysis bullosa

Explanation: **Explanation:** The clinical presentation of recurrent oral ulcers, genital ulcers, and ocular involvement (blurred vision) in a young male is the classic triad of **Behcet’s Syndrome**. **1. Why Behcet’s Syndrome is Correct:** Behcet’s is a systemic, chronic relapsing vasculitis of unknown etiology that affects vessels of all sizes (small, medium, and large). * **Mucocutaneous lesions:** Recurrent, painful aphthous ulcers in the mouth (most common) and on the genitals (scrotum/penis) [1]. * **Ocular involvement:** Uveitis (anterior or posterior) or retinal vasculitis leading to blurred vision or blindness. * **Systemic features:** It frequently involves the epididymis (epididymitis), joints (arthritis), and skin (erythema nodosum or acneiform lesions). **2. Analysis of Incorrect Options:** * **Oculocutaneous aphthous ulcer syndrome:** This is an outdated or non-specific descriptive term and not a recognized clinical entity in standard medical nomenclature like Behcet’s. * **Fabry’s Disease:** An X-linked lysosomal storage disorder characterized by angiokeratomas, peripheral neuropathy (burning pain), and renal/cardiac failure. It does not cause recurrent mucosal ulcers. * **Epidermolysis Bullosa:** A group of genetic disorders causing skin fragility and blistering due to mechanical trauma. While it can involve mucous membranes, it does not present with the systemic vasculitic triad seen here. **Clinical Pearls for NEET-PG:** * **Pathergy Test:** A highly specific diagnostic test where a sterile needle prick causes a pustule/papule within 24–48 hours. * **HLA Association:** Strongly associated with **HLA-B51**. * **Demographics:** Most common along the "Silk Road" (Mediterranean to East Asia). * **Treatment:** Colchicine for mucosal lesions; Azathioprine or Anti-TNF agents for ocular/systemic disease.

Question 568: Which of the following is NOT a characteristic of mixed connective tissue disease?

A. Hypogammaglobulinemia (Correct Answer)
B. Membranous glomerulonephritis
C. Polyarthritis
D. Central nervous system involvement

Explanation: **Explanation:** Mixed Connective Tissue Disease (MCTD), also known as Sharp’s Syndrome, is an overlap syndrome characterized by clinical features of Systemic Lupus Erythematosus (SLE), Systemic Sclerosis (Scleroderma), and Polymyositis, occurring in the presence of high titers of **anti-U1 RNP antibodies** [1]. **Why Hypogammaglobulinemia is the correct answer:** MCTD is characterized by immune system overactivity and B-cell hyperactivity. Therefore, patients typically present with **Hypergammaglobulinemia** (elevated levels of gamma globulins), not hypogammaglobulinemia. This hypergammaglobulinemia is often associated with a positive Rheumatoid Factor and high-titer ANA (speckled pattern) [2]. **Analysis of incorrect options:** * **Membranous glomerulonephritis:** While renal involvement is less common in MCTD than in SLE (occurring in about 25% of cases), when it does occur, membranous glomerulonephritis is the most frequent histological finding. * **Polyarthritis:** This is one of the most common presenting features of MCTD (seen in ~90% of patients). It often mimics Rheumatoid Arthritis but is typically non-erosive [1]. * **Central nervous system involvement:** Although less frequent than in SLE, CNS manifestations like trigeminal neuralgia (highly characteristic), aseptic meningitis, and peripheral neuropathy can occur in MCTD. **High-Yield Clinical Pearls for NEET-PG:** * **Serological Marker:** High titer of **anti-U1 RNP** is mandatory for diagnosis; antibodies to Sm (Smith) or dsDNA are usually absent [1]. * **Most Common Cause of Death:** Pulmonary Hypertension (unlike SLE, where renal failure/infections are leading causes) [1]. * **Raynaud’s Phenomenon:** Often the earliest clinical manifestation, seen in nearly all patients [1]. * **Hand Appearance:** "Puffy hands" or swollen fingers are a classic early sign [1].

Question 569: All the following are true about Rheumatoid arthritis except:

A. Positive for Anti-IgG antibody
B. Juxta-articular osteoporosis
C. Morning stiffness
D. C-reactive protein indicates better prognosis (Correct Answer)

Explanation: **Explanation:** In Rheumatoid Arthritis (RA), **C-reactive protein (CRP)** and Erythrocyte Sedimentation Rate (ESR) are markers of systemic inflammation [1]. High levels of CRP are associated with increased disease activity, progressive joint destruction, and a **poorer prognosis**, rather than a better one [1]. Therefore, Option D is the false statement. **Analysis of other options:** * **Option A (Positive for Anti-IgG antibody):** This refers to **Rheumatoid Factor (RF)**, which is an autoantibody (usually IgM) directed against the Fc portion of the patient's own IgG [1]. It is present in approximately 70-80% of RA patients. * **Option B (Juxta-articular osteoporosis):** This is one of the earliest radiographic hallmarks of RA. It occurs due to local cytokine-mediated (IL-1, TNF-α) activation of osteoclasts near the inflamed synovium [2]. * **Option C (Morning stiffness):** A classic clinical feature of inflammatory arthritis. In RA, morning stiffness typically lasts **more than 1 hour** and improves with activity, distinguishing it from osteoarthritis. **High-Yield Clinical Pearls for NEET-PG:** * **Most Specific Marker:** Anti-Cyclic Citrullinated Peptide (**Anti-CCP**) antibodies (Specificity >95%). * **Earliest X-ray Change:** Soft tissue swelling and juxta-articular osteopenia. * **Characteristic Deformities:** Swan-neck deformity, Boutonniere deformity, and Z-deformity of the thumb. * **Extra-articular Manifestation:** Rheumatoid nodules are the most common; Caplan syndrome (RA + Pneumoconiosis) is a frequent exam favorite [3]. * **Joint Sparing:** RA characteristically **spares the Distal Interphalangeal (DIP) joints**.

Question 570: Which of the following is NOT typically seen in inflammatory arthritis?

A. Raised ESR
B. Morning stiffness
C. Periarticular osteoporosis
D. New bone formation (Correct Answer)

Explanation: **Explanation:** The hallmark of **inflammatory arthritis** (e.g., Rheumatoid Arthritis) is synovial inflammation (synovitis), which leads to the release of pro-inflammatory cytokines like TNF-α and IL-1 [1]. These cytokines stimulate osteoclast activity, leading to bone resorption rather than formation. **Why "New bone formation" is the correct answer:** New bone formation (osteophytes, subchondral sclerosis, or syndesmophytes) is a characteristic feature of **degenerative joint disease (Osteoarthritis)** or **Seronegative Spondyloarthropathies** (like Ankylosing Spondylitis). In classic inflammatory arthritis like Rheumatoid Arthritis (RA), the process is primarily **erosive** [1]. The inflammatory milieu inhibits osteoblast function, preventing the formation of new bone at the site of inflammation. **Analysis of Incorrect Options:** * **Raised ESR:** Inflammatory cytokines (IL-6) stimulate the liver to produce acute-phase reactants [1]. Elevated ESR and CRP are standard systemic markers of active inflammation. * **Morning stiffness:** This is a classic clinical feature. In inflammatory arthritis, stiffness typically lasts **>1 hour** and improves with activity, whereas in non-inflammatory conditions, it lasts <30 minutes [2]. * **Periarticular osteoporosis:** This is one of the earliest radiological signs of RA. Localized cytokine release increases blood flow and activates osteoclasts in the bone adjacent to the inflamed joint, leading to focal bone loss [1]. **NEET-PG High-Yield Pearls:** * **RA Radiology Triad:** Periarticular osteopenia, uniform joint space narrowing, and marginal erosions. * **OA Radiology Triad:** Osteophytes, subchondral sclerosis, and asymmetrical joint space narrowing. * **Key Distinction:** If a question mentions "Eburnation" or "Subchondral cysts," think Osteoarthritis. If it mentions "Pannus" or "Symmetrical involvement," think Rheumatoid Arthritis.

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

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Antiphospholipid Syndrome

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