Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT a risk factor associated with the development of gout?

Female sex. The correct answer is **A. Female sex**. In the epidemiology of gout, male sex is a well-established risk factor. Estrogen has a **uricosuric effect** (it promotes the excretion of uric acid by the kidneys), which keeps serum urate levels lower in premenopausal women. Consequently, gout is significantly more common in men and postmenopausal women. **Analysis of Options:** * **Alcohol consumption (Option B):** This is a major risk factor. Alcohol (especially beer) increases urate production through purine metabolism and decreases urate excretion by increasing lactic acid levels, which competes with uric acid for renal excretion. * **Hyperlipidemia (Option C):** Gout is strongly associated with **Metabolic Syndrome**. Hypertriglyceridemia is frequently seen in gout patients, and the underlying insulin resistance associated with dyslipidemia reduces renal uric acid clearance [1]. * **Hypertension (Option D):** Hypertension is an independent risk factor for gout. Furthermore, many antihypertensive medications (specifically **Thiazide and Loop diuretics**) decrease urate excretion, precipitating hyperuricemia [3]. **High-Yield Clinical Pearls for NEET-PG:** * **The "Estrogen Protection":** Gout is rare in premenopausal women; if present, look for underlying renal disease or genetic enzymatic defects. * **Drug-Induced Gout:** Remember the mnemonic **CANT** (Cyclosporine, Alcohol, Nicotinic acid, Thiazides) for drugs that cause hyperuricemia [3]. * **Losartan Exception:** Unlike other ARBs or antihypertensives, **Losartan** has uricosuric properties and is the preferred agent for hypertensive patients with gout. * **Gold Standard Diagnosis:** Identification of **negatively birefringent, needle-shaped crystals** under polarized light microscopy [2].

Q: A 40-year-old woman presents with a several-year history of widespread body pain and stiffness, predominantly affecting her shoulders, upper back, hips, thighs, and knees. She also reports significant fatigue, requiring up to 14 hours of low-quality sleep daily, and cognitive difficulties described as feeling "not all there mentally". Her vital signs are stable. Physical examination reveals pain on palpation of the deltoids, trapezius, latissimus dorsi, and quadriceps muscles. She has no joint deformities, swelling, or redness. Which of the following is the most likely diagnosis?

Fibromyalgia. The clinical presentation is classic for **Fibromyalgia**, a chronic central pain amplification syndrome [1]. The diagnosis is based on the triad of **widespread musculoskeletal pain** (lasting >3 months), **fatigue** (unrefreshing sleep), and **cognitive dysfunction** (often termed "fibro-fog") [2]. 1. **Why Fibromyalgia is correct:** The patient exhibits pain in multiple quadrants (shoulders, back, hips, knees) without objective signs of inflammation (no swelling or redness). The description of "low-quality sleep" despite long hours and "not being all there mentally" are hallmark features [1]. While the older ACR criteria focused on specific "tender points," current criteria emphasize the **Widespread Pain Index (WPI)** and **Symptom Severity (SS) scale**, both of which are strongly positive here [1]. 2. **Why other options are incorrect:** * **Depression:** While frequently comorbid with fibromyalgia, it does not typically present with localized muscle tenderness and widespread physical pain as the primary complaint. * **Obstructive Sleep Apnea (OSA):** While OSA causes daytime fatigue and cognitive lag, it does not explain the widespread musculoskeletal pain or the specific muscle tenderness noted on examination [1]. * **Peripheral Neuropathy:** This usually presents with "stocking-glove" sensory loss, tingling, or burning in distal extremities, rather than proximal muscle pain and stiffness. **High-Yield Clinical Pearls for NEET-PG:** * **Pathophysiology:** Central sensitization (increased sensitivity to pain signals in the CNS) [1]. * **Demographics:** Most common in women aged 20–50. * **Lab Findings:** Inflammatory markers (ESR, CRP) and muscle enzymes (CPK) are **characteristically normal** [1]. * **Management:** First-line involves patient education and aerobic exercise [1]. Pharmacotherapy includes **TCAs (Amitriptyline)**, **SNRIs (Duloxetine)**, or **Gabapentinoids (Pregabalin)**. Avoid opioids.

Q: All are included in the criteria for diagnosis of systemic lupus erythematosus, except?

Painful oral ulcers. In Systemic Lupus Erythematosus (SLE), the characteristic mucosal involvement is typically **painless oral ulcers**. This is a high-yield distinction in rheumatology. ### **Explanation of the Correct Answer** **D. Painful oral ulcers:** According to both the ACR (American College of Rheumatology) and SLICC criteria, the diagnostic feature is **painless** oral or nasopharyngeal ulceration, usually observed by a physician. Painful ulcers are more commonly associated with conditions like Behçet’s disease, Crohn’s disease, or simple aphthous stomatitis. ### **Analysis of Incorrect Options** * **A. Photosensitivity:** This is a classic ACR criterion. It refers to a skin rash resulting from an unusual reaction to sunlight, either by patient history or physician observation [1]. * **B. Malar rash:** Also known as the "butterfly rash," it is a fixed erythema (flat or raised) over the malar eminences, characteristically **sparing the nasolabial folds** [1]. * **C. Discoid rash:** These are erythematous raised patches with adherent keratotic scaling and follicular plugging; they often lead to atrophic scarring [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **Most Common Symptom:** Joint pain/Arthralgia (90% of patients). * **Most Specific Test:** Anti-dsDNA or Anti-Smith (Anti-Sm) antibodies. * **Best Screening Test:** ANA (High sensitivity, low specificity). * **Drug-Induced Lupus:** Characterized by **Anti-Histone antibodies**; usually spares the CNS and Kidneys. * **Complement Levels:** Low C3 and C4 levels indicate active disease, especially lupus nephritis. * **Libman-Sacks Endocarditis:** A specific cardiac manifestation involving non-bacterial verrucous vegetations on both sides of the heart valves.

Q: All of the following are extraglandular manifestations of primary Sjögren's syndrome except?

Thrombocytopenia. Primary Sjögren’s Syndrome (pSS) is a systemic autoimmune disease characterized by lymphocytic infiltration of exocrine glands (Sicca symptoms). However, up to 30-50% of patients develop **extraglandular manifestations (EGM)**. **Why Thrombocytopenia is the correct answer:** While hematological abnormalities are common in pSS, the most characteristic finding is **Leukopenia** (specifically lymphopenia) and anemia of chronic disease. **Thrombocytopenia** is relatively rare in primary Sjögren’s. If significant thrombocytopenia occurs, clinicians should investigate for an overlap syndrome (like SLE) or the development of Lymphoma. **Analysis of Incorrect Options:** * **Raynaud’s Phenomenon (Option A):** This is a very common EGM, occurring in approximately 13-30% of patients, often predating sicca symptoms by years. * **Arthritis (Option B):** Musculoskeletal involvement is the most frequent EGM. It typically presents as a symmetrical, non-erosive polyarthritis or arthralgia, similar to Rheumatoid Arthritis but less destructive. * **Lymphoma (Option C):** Patients with pSS have a **44-fold increased risk** of developing B-cell Non-Hodgkin Lymphoma (specifically MALT lymphoma). This is the most serious complication of the disease. **NEET-PG High-Yield Pearls:** 1. **Most common EGM:** Arthralgia/Arthritis. 2. **Most common Hematological finding:** Leukopenia/Anemia (NOT thrombocytopenia). 3. **Predictors of Lymphoma:** Persistent parotid swelling, purpura, low C4 levels, and mixed cryoglobulinemia. 4. **Antibody Profile:** Anti-Ro (SS-A) and Anti-La (SS-B) are characteristic [1]; Anti-Ro is associated with earlier onset and higher frequency of EGMs. 5. **Renal involvement:** Most commonly presents as **Tubulointerstitial Nephritis (TIN)**, often leading to Distal Renal Tubular Acidosis (Type 1 RTA).

Question 1

A patient presents with musculoskeletal complaints. What feature is suggestive of a non-articular origin of pain?

Accepted Answer

Pain on active movement but not on passive movement

Answer

Pain or decreased range of motion on both active and passive movement

Answer

Swelling

Answer

Crepitation

Question 2

A 30-year-old male presented with painful, deep recurrent oral aphthous ulcers. The ulcers had a yellowish necrotic base and appeared in crops. Painful genital ulcers and skin lesions were also seen. A test was performed wherein normal saline was injected intradermally. Bilateral panuveitis was noted on ophthalmoscopic examination. The patient also complained of arthralgia in bilateral knee joints. Lab findings revealed leukocytosis, raised ESR, and raised CRP. Which of the following antibodies can be seen in this condition?

Accepted Answer

ASCA Ab, Ab against ALPHA-ENOLASE, and Ab against selenium binding protein

Answer

ASCA Ab, ANCA Ab, and Anti-histone Ab

Answer

ASCA Ab, Ab against ALPHA-ENOLASE, and Anti-histone Ab

Answer

ANCA Ab, Ab against ALPHA-ENOLASE, and Ab against selenium binding protein

Question 3

A patient presents with severe pain and swelling in the great toe. Which of the following statements regarding gout are true?

Accepted Answer

High serum uric acid levels may not be present.

Answer

Allopurinol is used in the acute control of gout.

Answer

Colchicine acts slowly.

Answer

Colchicine causes gastrointestinal disturbances.

Question 4

A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On exam, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. What is the next step in evaluation?

Accepted Answer

Schirmer test and measurement of autoantibodies

Answer

Lip biopsy

Answer

IgG antibody to mumps virus

Answer

Use of corticosteroids

Question 5

Hormonal abnormalities in men and post-menopausal women suffering from rheumatoid arthritis include the following, except?

Accepted Answer

Decreased thyroid autoantibodies

Answer

Decreased testosterone

Answer

Decreased luteinizing hormone

Answer

Decreased dehydroepiandrosterone

Question 6

Which of the following is NOT a risk factor associated with the development of gout?

Accepted Answer

Female sex

Answer

Alcohol consumption

Answer

Hyperlipidemia

Answer

Hypertension

Question 7

A 40-year-old woman presents with a several-year history of widespread body pain and stiffness, predominantly affecting her shoulders, upper back, hips, thighs, and knees. She also reports significant fatigue, requiring up to 14 hours of low-quality sleep daily, and cognitive difficulties described as feeling "not all there mentally". Her vital signs are stable. Physical examination reveals pain on palpation of the deltoids, trapezius, latissimus dorsi, and quadriceps muscles. She has no joint deformities, swelling, or redness. Which of the following is the most likely diagnosis?

Accepted Answer

Fibromyalgia

Answer

Depression

Answer

Obstructive sleep apnea

Answer

Peripheral neuropathy

Question 8

All are included in the criteria for diagnosis of systemic lupus erythematosus, except?

Accepted Answer

Painful oral ulcers

Answer

Photosensitivity

Answer

Malar rash

Answer

Discoid rash

Question 9

Which condition has a >90% association with HLA-B27?

Accepted Answer

Ankylosing spondylitis

Answer

Enteropathic arthritis

Answer

Reactive arthritis

Answer

Rheumatoid arthritis

Question 10

All of the following are extraglandular manifestations of primary Sjögren's syndrome except?

Accepted Answer

Thrombocytopenia

Answer

Raynaud's phenomena

Answer

Arthritis

Answer

Lymphoma

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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