Rheumatology and Immunology Practice Questions

Q: Which condition characteristically involves the lungs?

Churg-Strauss syndrome. **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.

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

Five. 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.

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

Swelling and warmth. ### 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**.

Q: ASO titre is diagnostic in?

Acute rheumatic fever. ### 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.

Q: 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?

Behcet syndrome. **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.

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

Hypogammaglobulinemia. **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].

Q: All the following are true about Rheumatoid arthritis except:

C-reactive protein indicates better prognosis. **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**.

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

New bone formation. **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.

Question 1

Which condition characteristically involves the lungs?

Accepted Answer

Churg-Strauss syndrome

Answer

Henoch-Schönlein purpura (HSP)

Answer

Polyarteritis nodosa (PAN)

Answer

Idiopathic thrombocytopenic purpura (ITP)

Question 2

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

Accepted Answer

Five

Answer

One

Answer

Two

Answer

Four

Question 3

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

Accepted Answer

Swelling and warmth

Answer

Painful range of motion

Answer

Crepitus

Answer

Bony articular enlargement

Question 4

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

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Rheumatic fever

Answer

Hypertension

Answer

Diabetes mellitus

Question 5

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

Accepted Answer

Anti-centromere antibody positivity is a predictor of skin and lung involvement

Answer

Accelerated hypertension

Answer

Onion skinning of renal vessels

Answer

ACE inhibitors reduce mortality rate

Question 6

ASO titre is diagnostic in?

Accepted Answer

Acute rheumatic fever

Answer

SBE (Subacute bacterial endocarditis)

Answer

Rheumatoid arthritis

Answer

Infective endocarditis

Question 7

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?

Accepted Answer

Behcet syndrome

Answer

Oculocutaneous aphthous ulcer syndrome

Answer

Fabry's disease

Answer

Epidermolysis bullosa

Question 8

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

Accepted Answer

Hypogammaglobulinemia

Answer

Membranous glomerulonephritis

Answer

Polyarthritis

Answer

Central nervous system involvement

Question 9

All the following are true about Rheumatoid arthritis except:

Accepted Answer

C-reactive protein indicates better prognosis

Answer

Positive for Anti-IgG antibody

Answer

Juxta-articular osteoporosis

Answer

Morning stiffness

Question 10

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

Accepted Answer

New bone formation

Answer

Raised ESR

Answer

Morning stiffness

Answer

Periarticular osteoporosis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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