Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT a feature of Ankylosing spondylitis (AS)?

The Roos test is used to test for Sacroiliitis.. Explanation: 1. Why Option C is the correct answer (The False Statement): The Roos test (also known as the "Elevated Arm Stress Test") is used to diagnose Thoracic Outlet Syndrome, not sacroiliitis. It involves the patient repeatedly opening and closing their hands with arms abducted and elbows flexed for 3 minutes. Sacroiliitis in AS is typically assessed using the Schober’s test (for lumbar spine mobility) or the FABER (Patrick’s) test and Gaenslen’s test (for sacroiliac joint pain). 2. Analysis of Incorrect Options (True Features of AS): * Options A & B: The pathogenesis of AS is unique because it involves a progression from inflammation to fibrous ankylosis, which eventually undergoes ossification [1] to become bony ankylosis [3]. This leads to the characteristic "fused" or "bamboo spine" [3]. * Option D: Marginal syndesmophytes are a hallmark radiographic feature of AS [3]. These are thin, vertical bony outgrowths that bridge the vertebral bodies, resulting from the ossification of the outer fibers of the annulus fibrosus [1]. (Note: Non-marginal syndesmophytes are seen in Psoriatic Arthritis [3]). Clinical Pearls for NEET-PG: * HLA-B27: Strongly associated (>90% of cases) but not diagnostic [2]. * Earliest Sign: Sacroiliitis (usually bilateral and symmetrical) is the earliest radiographic change [1]. * Extra-articular manifestation: Acute Anterior Uveitis is the most common (unilateral, painful, red eye) [2]. * Modified New York Criteria: The gold standard for diagnosis, requiring both clinical and radiological evidence [3]. * Treatment of Choice: NSAIDs are first-line; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Q: Reactive arthritis is usually caused by which pathogen?

Shigella flexneri. Reactive arthritis (formerly Reiter’s syndrome) is a sterile joint inflammation that develops following a distant infection, typically of the gastrointestinal (GI) or urogenital tract. [1] It is strongly associated with the **HLA-B27** genotype. [1] **Why Shigella flexneri is correct:** Among the various species of *Shigella*, **Shigella flexneri** is the most common trigger for reactive arthritis following bacillary dysentery. While many enteric pathogens can trigger the condition, *S. flexneri* has a specific propensity to induce the immune-mediated joint response seen in susceptible individuals. **Analysis of Incorrect Options:** * **Shigella boydii & Shigella shiga:** These species are rare causes of dysentery in most regions and are not classically associated with the development of reactive arthritis in medical literature or clinical studies. * **Shigella dysenteriae:** While this species causes the most severe form of clinical dysentery (Type 1) and can lead to Hemolytic Uremic Syndrome (HUS), it is significantly less likely to trigger reactive arthritis compared to *S. flexneri*. **Clinical Pearls for NEET-PG:** * **Common Triggers:** * **Enteric:** *Shigella flexneri*, *Salmonella*, *Campylobacter jejuni*, and *Yersinia enterocolitica*. [1] * **Urogenital:** *Chlamydia trachomatis* (the most common cause overall). [1] * **Classic Triad:** "Can't see, can't pee, can't climb a tree" (Uveitis/Conjunctivitis, Urethritis, and Arthritis). [1] * **Key Findings:** Look for **keratoderma blennorrhagica** (skin lesions on palms/soles) and **circinate balanitis**. [1] * **Joint Involvement:** Typically an asymmetric oligoarthritis affecting the lower extremities (knees and ankles). [1]

Q: A person presented with swelling of the right 3rd toe. X-ray shows deposition of multiple crystals. A defect in which of the following pathways caused the problem?

Uric acid pathway. ***Uric acid pathway*** - Swelling of the toe with **crystal deposition** on X-ray is characteristic of **gout**, caused by **monosodium urate crystals** depositing in joints due to hyperuricemia. - Defects in **uric acid metabolism** lead to increased uric acid production or decreased excretion, resulting in crystal formation and joint inflammation. *Purine salvage pathway* - While **HGPRT deficiency** (Lesch-Nyhan syndrome) can cause hyperuricemia, it's a secondary effect rather than the primary pathway defect causing gout. - The purine salvage pathway defect would present with **neurological symptoms** and **self-mutilation** in severe cases, not isolated joint swelling. *Urea cycle* - The **urea cycle** is involved in **ammonia detoxification** and nitrogen disposal, not uric acid metabolism. - Defects cause **hyperammonemia** with neurological symptoms like confusion and coma, not crystal arthropathy. *CORI cycle* - The **CORI cycle** involves **lactate-glucose interconversion** between muscle and liver during exercise and fasting. - This metabolic pathway has no relation to **uric acid production** or crystal deposition in joints.

Q: Which of the following is FALSE about Sjögren's syndrome?

Parotid gland biopsy is preferred. Sjögren's syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of exocrine glands, primarily the lacrimal and salivary glands. **Why Option C is the Correct (False) Statement:** While the parotid gland is frequently enlarged in Sjögren's syndrome, a **minor salivary gland biopsy (usually from the lower lip)** is the preferred diagnostic procedure. It is less invasive, carries a lower risk of facial nerve injury or salivary fistula formation, and provides the characteristic "focus score" (≥1 focus of 50 lymphocytes per 4 $mm^2$ of tissue) required for classification criteria. **Analysis of Other Options:** * **Option A (True):** Keratoconjunctivitis sicca (dry eyes) results from lymphocytic infiltration of the lacrimal glands, leading to decreased tear production and corneal damage. * **Option B (True):** The hallmark histopathology of Sjögren's is a progressive **periductal and perivascular lymphocytic infiltration** (predominantly CD4+ T cells), which eventually leads to acinar atrophy and fibrosis. * **Option C (True):** Patients with Sjögren's have a 40-fold increased risk of developing B-cell lymphomas. The most common type is **MALToma** (Mucosa-Associated Lymphoid Tissue lymphoma), typically occurring in the parotid glands. **High-Yield Clinical Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are the most specific markers. * **Schirmer’s Test:** Used to quantify tear production (<5 mm in 5 minutes is positive). * **Extraglandular Manifestations:** Include Raynaud’s phenomenon, cutaneous vasculitis, and interstitial lung disease. * **Risk Factor for Lymphoma:** Persistent parotid enlargement, purpura, and low C4 levels are warning signs of malignant transformation.

Q: A patient presents with gritty pain in the eye and joint pain, following a recent urinary tract infection. What is the most probable diagnosis?

Reiter's syndrome. ### Explanation **Correct Option: A. Reiter’s Syndrome (Reactive Arthritis)** Reiter’s syndrome is a clinical triad of **non-gonococcal urethritis, conjunctivitis (or uveitis), and arthritis** [1]. It is a type of Seronegative Spondyloarthropathy that typically follows an infection of the urogenital tract (e.g., *Chlamydia trachomatis*) or the gastrointestinal tract (e.g., *Salmonella*, *Shigella*) [1]. In this case, the "gritty pain in the eye" indicates conjunctivitis, and the joint pain following a urinary tract infection (UTI) fits the classic "Can't see, can't pee, can't climb a tree" mnemonic. **Why other options are incorrect:** * **B. Behçet’s Syndrome:** Characterized by the triad of oral ulcers, genital ulcers, and uveitis. While it involves the eyes and joints, it is not typically preceded by a UTI and is defined by painful aphthous ulcers. * **C. Sarcoidosis:** A multisystem granulomatous disease. While it can cause uveitis and arthritis (Lofgren’s syndrome), it usually presents with bilateral hilar lymphadenopathy and respiratory symptoms rather than a post-UTI onset. * **D. Systemic Lupus Erythematosus (SLE):** An autoimmune disease presenting with malar rash, photosensitivity, and polyarthritis. It does not typically follow an acute UTI and has a different clinical profile (ANA positivity). **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly associated with **HLA-B27** (approx. 80% of cases) [1]. * **Skin Findings:** Look for **Keratoderma blennorrhagicum** (vesicular, crusty lesions on palms/soles) and **Circinate balanitis** [1]. * **Joint Involvement:** Typically an asymmetric oligoarthritis affecting large joints of the lower extremities (e.g., knees, ankles) [1]. * **Dactylitis:** "Sausage digits" are a common feature.

Q: Which of the following is NOT an ANCA-associated vasculitis?

Anti-GBM disease. The classification of small-vessel vasculitis is primarily based on the presence or absence of immune deposits. **ANCA-associated vasculitides (AAV)** are characterized by "pauci-immune" inflammation (minimal or no immunoglobulin deposition) and the presence of Antineutrophil Cytoplasmic Antibodies [3]. **Why Anti-GBM disease is the correct answer:** Anti-GBM (Glomerular Basement Membrane) disease, formerly known as Goodpasture’s syndrome, is **not** an ANCA-associated vasculitis. It is an **immune-complex mediated** disease caused by direct autoantibodies against the alpha-3 chain of Type IV collagen [3]. On immunofluorescence, it shows a characteristic **linear deposition** of IgG along the glomerular capillaries [1], unlike the "pauci-immune" (negative) staining seen in AAV. **Analysis of incorrect options:** * **A. Granulomatosis with polyangiitis (GPA):** Formerly Wegener’s. A classic AAV characterized by granulomatous inflammation of the respiratory tract and necrotizing vasculitis. * **B. Eosinophilic granulomatosis with polyangiitis (EGPA):** Formerly Churg-Strauss. An AAV characterized by asthma, peripheral eosinophilia, and granulomatous inflammation [2]. Associated with **p-ANCA (anti-MPO)** in about 40-50% of cases. * **C. Microscopic polyangiitis (MPA):** A necrotizing AAV that lacks granulomas. It frequently involves the kidneys (RPGN) and lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Double Positive:** Approximately 10-40% of patients with Anti-GBM disease also test positive for ANCA (usually p-ANCA). These patients have a "dual-positive" profile and carry a prognosis intermediate between the two diseases. * **Pauci-immune Glomerulonephritis:** If a biopsy shows necrotizing crescentic GN with *negative* immunofluorescence, the diagnosis is almost always an ANCA-associated vasculitis [3]. * **C-ANCA vs. P-ANCA:** Remember **C**-ANCA for **C**entral (PR3) and **P**-ANCA for **P**eriduclear (MPO).

Question 1

Which of the following is NOT a feature of Ankylosing spondylitis (AS)?

Accepted Answer

The Roos test is used to test for Sacroiliitis.

Answer

Fibrous ankylosis is part of the pathogenesis of AS.

Answer

Bony ankylosis is part of the pathogenesis of AS.

Answer

Marginal syndesmophytes are seen on X-ray.

Question 2

A patient presents with melaena, normal renal function, hypertension, and mononeuritis multiplex. What is the most probable diagnosis?

Accepted Answer

Classical polyarteritis nodosa

Answer

Microscopic polyangiitis

Answer

Henoch-Schonlein purpura

Answer

Buerger's disease

Question 3

Reactive arthritis is usually caused by which pathogen?

Accepted Answer

Shigella flexneri

Answer

Shigella boydii

Answer

Shigella shiga

Answer

Shigella dysenteriae

Question 4

A patient with primary Sjogren syndrome treated with tear replacement for symptomatic relief notes continued parotid swelling for the last 3 months. She also has enlarged posterior cervical lymph nodes. Evaluation shows leukopenia and low C4 complement levels. What is the most likely diagnosis?

Accepted Answer

Lymphoma

Answer

Amyloidosis

Answer

Chronic pancreatitis

Answer

HIV infection

Question 5

A person presented with swelling of the right 3rd toe. X-ray shows deposition of multiple crystals. A defect in which of the following pathways caused the problem?

Accepted Answer

Uric acid pathway

Answer

Purine salvage pathway

Answer

Urea cycle

Answer

CORI cycle

Question 6

A 25-year-old male presented to the OPD with a complaint of recurrent oral ulcers and congested eyes. On enquiry, he has a history of prior hospital admission for venous thrombosis. What is the condition he is suffering from?

Accepted Answer

Behcet's disease

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Reiter's syndrome

Answer

Wegener's Granulomatosis

Question 7

Which of the following is FALSE about Sjögren's syndrome?

Accepted Answer

Parotid gland biopsy is preferred

Answer

Keratoconjunctivitis sicca

Answer

Periductal and perivascular lymphocytic infiltration

Answer

MALToma is the most common lymphoma

Question 8

A 72-year-old man is newly diagnosed with bullous pemphigoid. Which of the following is the most appropriate next step in the management?

Accepted Answer

High-dose prednisone (50-100 mg/day)

Answer

Plasmapheresis

Answer

Low-dose prednisone (10-20 mg/day)

Answer

Azathioprine (150 mg/day)

Question 9

A patient presents with gritty pain in the eye and joint pain, following a recent urinary tract infection. What is the most probable diagnosis?

Accepted Answer

Reiter's syndrome

Answer

Behçet's syndrome

Answer

Sarcoidosis

Answer

Systemic Lupus Erythematosus

Question 10

Which of the following is NOT an ANCA-associated vasculitis?

Accepted Answer

Anti-GBM disease

Answer

Granulomatosis with polyangiitis

Answer

Eosinophilic granulomatosis with polyangiitis

Answer

Microscopic polyangiitis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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