Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 731: In gout tophi are not seen in?

A. Nasal cartilage
B. Skin
C. Synovium
D. Muscles (Correct Answer)

Explanation: ***Muscles*** - **Muscles** are not a typical site for the formation of **tophi** in gout because they have a rich blood supply and are constantly undergoing metabolic activity, aiding in the clearance of uric acid crystals. - Tophaceous deposits primarily occur in tissues with **poor vascularity** and lower temperatures, where uric acid crystals can more easily precipitate and accumulate. *Nasal cartilage* - **Cartilage**, including the **nasal cartilage**, is a common site for tophi due to its **avascular** nature, which allows for easier deposition of **uric acid crystals** [1]. - Tophi in cartilage can manifest as painless or tender nodules. *Skin* - **Skin**, especially around joints or on the ear helix, is a frequent location for **tophi** formation, appearing as subcutaneous nodules [1]. - These deposits are often visible through the skin and can ulcerate if left untreated [1]. *Synovium* - The **synovium** is a primary target of gout, with **uric acid crystal deposition** leading to inflammatory arthritis [2]. - While acute inflammation involves the release of crystals into the synovial fluid, persistent high urate levels can lead to **tophaceous deposits** within the synovial membrane itself, contributing to chronic joint damage [1].

Question 732: Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swelling of tongue. Most likely diagnosis is:

A. Foreign body bronchus
B. Angioneurotic edema (Correct Answer)
C. Foreign body larynx
D. Pharyngeal abscess

Explanation: ***Angioneurotic edema*** - The rapid onset of **laryngeal edema**, **stridor**, **hoarseness**, and **tongue swelling** following peanut consumption points to an allergic reaction, specifically **anaphylaxis** causing angioedema [1], [2]. - This is a life-threatening condition due to potential **airway obstruction**. *Foreign body bronchus* - While a foreign body could cause **stridor** if large enough to impact the trachea, symptoms like **laryngeal edema** and **tongue swelling** are not typical. - It usually presents with sudden coughing, wheezing, and possibly dyspnea, often without rapid-onset, diffuse swelling. *Foreign body larynx* - A foreign body in the larynx might cause hoarseness and stridor, but **laryngeal edema** and **tongue swelling** are not primary features of a simple foreign body obstruction. - The history of peanut ingestion and rapid systemic inflammatory response makes an allergic reaction more likely [2]. *Pharyngeal abscess* - A pharyngeal abscess typically develops more slowly, with symptoms including **severe sore throat**, **fever**, and **difficulty swallowing**. - It would not usually present with the rapid onset of severe **laryngeal edema** and **tongue swelling** immediately after peanut consumption.

Question 733: Which of the following cardiac complications may develop in a 33 year old woman with systemic lupus erythematosus (SLE) because of her underlying condition?

A. Mitral valve prolapse
B. Libman-Sacks endocarditis (Correct Answer)
C. Hemorrhagic pericarditis
D. Infective endocarditis

Explanation: ***Libman-Sacks endocarditis*** - Libman-Sacks endocarditis is a **non-infectious valvular vegetation** that is highly characteristic of **systemic lupus erythematosus (SLE)** [3]. - These vegetations can lead to **valvular incompetence** or **stenosis**, primarily affecting the **mitral and aortic valves** [1]. *Mitral valve prolapse* - While mitral valve prolapse can occur in SLE patients, it is a relatively common condition in the general population and is **not as specifically linked** to SLE pathology as Libman-Sacks endocarditis. - It involves the **leaflet(s) of the mitral valve bulging** back into the left atrium during systole, which causes a **mid-systolic click and late systolic murmur**, but does not represent the specific immune-mediated damage seen in SLE. *Hemorrhagic pericarditis* - Pericarditis is a common cardiac manifestation in SLE, leading to **inflammation of the pericardium**, but it is typically **serous or fibrinous**, not usually hemorrhagic. - **Hemorrhagic pericarditis** is more often associated with conditions like malignancy, tuberculosis, or trauma, and is not a typical presentation of SLE. *Infective endocarditis* - **Infective endocarditis** is caused by microbial infection of the heart valves, resulting in **vegetations containing bacteria or fungi** [2]. - While SLE patients can be at increased risk for infections due to immunosuppression, the vegetations of Libman-Sacks endocarditis are **sterile (non-infectious)** and distinct in their underlying pathophysiology [1].

Question 734: All are true regarding Ankylosing spondylitis except -

A. Sacroilitis
B. HLA -B27
C. More common in females (Correct Answer)
D. Iridocyclitis

Explanation: ***More common in females*** - **Ankylosing spondylitis** (AS) is **more common in males** than females, with a male-to-female ratio typically ranging from 2:1 to 3:1. - While females can be affected, their disease presentation might be milder and diagnosis often delayed. *Sacroilitis* - **Sacroiliitis** is a hallmark feature and often the **earliest radiographic finding** in ankylosing spondylitis, characterized by inflammation of the sacroiliac joints [1]. - It is crucial for the diagnosis of AS, causing **buttock pain** and stiffness [1]. *HLA -B27* - The presence of the **HLA-B27** allele is strongly associated with ankylosing spondylitis, found in **90-95% of Caucasian patients** with AS [1]. - While not diagnostic on its own, it significantly increases the risk and supports the diagnosis in conjunction with clinical and imaging findings [1]. *Iridocyclitis* - **Acute anterior uveitis (iritis or iridocyclitis)** is a common **extra-articular manifestation** of ankylosing spondylitis, affecting approximately 25-40% of patients [1]. - It presents with **eye pain**, redness, and photophobia, and can precede or follow the onset of joint symptoms.

Question 735: Which of the following is true about psoriatic arthritis

A. Sacroiliitis is a common feature
B. Pencil in cup deformity is a radiological finding
C. Involves distal joints of hand and foot and proximal interphalangeal joints
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - **Psoriatic arthritis** is a seronegative spondyloarthropathy [2] that can manifest with a wide range of joint involvement, including **sacroiliitis**, characteristic radiological changes like **pencil-in-cup deformity**, and involvement of both **distal** and **proximal interphalangeal joints** [1]. *Sacroiliitis is a common feature* - **Sacroiliitis** occurs in approximately 20-40% of patients with psoriatic arthritis, contributing to inflammatory back pain. - It is often **asymmetrical** and can be detected radiographically [1], distinguishing it from the typically symmetrical sacroiliitis of ankylosing spondylitis. *Pencil in cup deformity is a radiological finding* - This characteristic radiological finding, known as **arthritis mutilans**, is seen in a severe subtype of psoriatic arthritis where there is **osteolysis** of the phalanx and telescoping of the digit [2]. - It results from severe bone erosion at the joint margins, creating a "pencil-in-cup" appearance. *Involves distal joints of hand and foot and proximal interphalangeal joints* - **DIP joint involvement** (distal interphalangeal) is a classic feature of psoriatic arthritis, distinguishing it from rheumatoid arthritis [1], [2]. - Involvement of the **PIP joints** (proximal interphalangeal) and other peripheral joints is also common [1], along with **dactylitis** (sausage digits) and **enthesitis**.

Question 736: Bechterew disease is?

A. Ankylosing spondylitis (Correct Answer)
B. Behçet's disease
C. Sjogren's syndrome
D. Psoriasis

Explanation: ***Ankylosing spondylitis*** - **Bechterew disease** is an older term sometimes used to refer to **ankylosing spondylitis**. [1] - It is a chronic inflammatory disease primarily affecting the **axial skeleton**, including the spine and sacroiliac joints. [1] *Beh''et''s disease* - This is a separate chronic, systemic inflammatory disease characterized by **recurrent oral and genital ulcers**, **skin lesions**, and **ocular involvement**. - It does not primarily affect the spine in the same way as ankylosing spondylitis and is not known as Bechterew disease. *Sjogren''s syndrome* - This is an **autoimmune disease** primarily characterized by **dry eyes** (**xerophthalmia**) and **dry mouth** (**xerostomia**) due to lymphocytic infiltration of exocrine glands. - It is not referred to as Bechterew disease and has distinct clinical features from ankylosing spondylitis. *Psoriasis* - This is a chronic **autoimmune skin condition** characterized by red, scaly patches on the skin, often associated with **psoriatic arthritis**. [1] - While psoriatic arthritis can involve the spine, psoriasis itself is a skin condition and is not synonymous with Bechterew disease. [1]

Question 737: Seronegative spondarthritides includes all EXCEPT

A. Reiter's syndrome
B. Rheumatoid arthritis (Correct Answer)
C. Ankylosing spondylitis
D. Psoriatic arthritis

Explanation: ***Rheumatoid arthritis*** - Rheumatoid arthritis (RA) is characterized by the presence of **rheumatoid factor (RF)** and/or **anti-cyclic citrullinated peptide (anti-CCP) antibodies**, making it a **seropositive** arthropathy. [1] - While it causes an inflammatory arthritis, its serological markers differentiate it from the seronegative spondyloarthropathies. *Reiter's syndrome* - Reiter's syndrome, now commonly referred to as **reactive arthritis**, is a classic example of a seronegative spondyloarthropathy. [1] - It is often triggered by an infection and is typically **RF-negative** and **HLA-B27 positive**. *Ankylosing spondylitis* - **Ankylosing spondylitis (AS)** is a prototypical seronegative spondyloarthropathy, characterized by inflammation primarily affecting the **spine and sacroiliaciac joints**. [1] - It is defined by the **absence of RF** and **anti-CCP antibodies**, though it is strongly associated with **HLA-B27**. *Psoriatic arthritis* - **Psoriatic arthritis (PsA)** is another member of the seronegative spondyloarthropathies, occurring in individuals with **psoriasis**. [1] - Like other conditions in this group, patients with PsA are typically **negative for RF** and **anti-CCP antibodies**.

Question 738: Anti-histone antibodies are specific for:

A. Neonatal lupus
B. CNS lupus
C. Drug induced lupus (Correct Answer)
D. Cutaneous lupus

Explanation: ***Drug induced lupus*** - **Anti-histone antibodies** are highly sensitive (up to 95%) for **drug-induced lupus erythematosus (DILE)**, making them a key diagnostic marker. - DILE typically resolves after discontinuation of the offending drug, and the presence of these antibodies helps differentiate it from systemic lupus erythematosus (SLE) [1]. *Neonatal lupus* - **Neonatal lupus** is associated with **anti-Ro/SSA** and **anti-La/SSB antibodies**, which are passively acquired from the mother [1]. - It primarily presents with skin rash and/or congenital heart block, not typically associated with anti-histone antibodies. *CNS lupus* - **Central nervous system (CNS) lupus** is a manifestation of **systemic lupus erythematosus (SLE)** and is associated with various autoantibodies, including **anti-ribosomal P protein antibodies** and sometimes anti-neuronal antibodies. - While patients with SLE can have anti-histone antibodies, they are not specific for CNS involvement, and other antibody profiles are more relevant to CNS manifestations. *Cutaneous lupus* - **Cutaneous lupus erythematosus (CLE)** can be a standalone condition or part of SLE; it is typically associated with **anti-Ro/SSA antibodies** in subacute cutaneous lupus and sometimes **anti-dsDNA antibodies** in acute cutaneous lupus [2]. - **Anti-histone antibodies** are not a primary diagnostic marker for the various forms of cutaneous lupus.

Question 739: A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis. (SELECT 1 DIAGNOSIS)

A. Behcet syndrome
B. Ankylosing spondylitis
C. Polymyalgia rheumatica
D. Polyarteritis nodosa (Correct Answer)

Explanation: ***Polyarteritis nodosa*** - The combination of **fever**, **weight loss**, **hypertension**, **peripheral neuropathy**, **nodular skin rash**, **elevated ESR**, and **RBC casts** (indicating glomerulonephritis) is highly suggestive of **polyarteritis nodosa**. Systemic vasculitis should be considered in any patient with fever, weight loss, and multisystem involvement [1]. - **Polyarteritis nodosa** is a systemic vasculitis characterized by necrotizing inflammation of medium-sized arteries, often associated with a history of **drug abuse** and can involve multiple organ systems leading to the described symptoms [1]. *Behcet syndrome* - Characterized by recurrent **oral** and **genital ulcers**, and **uveitis**, which are not mentioned in this patient presentation. - While it can manifest with skin lesions and vasculitis, the specific constellation of symptoms, including hypertension and RBC casts, points away from **Behcet syndrome**. *Ankylosing spondylitis* - Primarily affects the **axial skeleton**, causing chronic back pain and stiffness, particularly in younger males. - It does not typically present with the systemic symptoms like **hypertension**, **nodular rash**, or **RBC casts** seen in this patient. *Polymyalgia rheumatica* - Characterized by **proximal muscle pain** and stiffness, predominantly in the shoulders, neck, and hip girdle, in older adults. - It is not associated with **hypertension**, **peripheral neuropathy**, **nodular skin rash**, or **renal involvement** (RBC casts) as described.

Question 740: In osteoarthritis, Bouchard nodes and Heberden's nodes are seen respectively at:

A. PIP and DIP (Correct Answer)
B. DIP and MCP
C. DIP and PIP
D. Palm and DIP

Explanation: ***PIP and DIP*** - **Bouchard nodes** are bony enlargements of the **proximal interphalangeal (PIP) joints** of the fingers due to osteophyte formation. - **Heberden's nodes** are similar bony enlargements found on the **distal interphalangeal (DIP) joints** of the fingers. *DIP and MCP* - This option incorrectly associates Heberden's nodes with the MCP joints and does not correctly identify the location for Bouchard nodes. - While DIP joints are affected by Heberden's nodes, the **metacarpophalangeal (MCP) joints** are typically spared or less commonly involved in osteoarthritis compared to PIP and DIP joints. *DIP and PIP* - This option incorrectly reverses the locations for Bouchard and Heberden's nodes. - **Bouchard nodes** are found on the **PIP joints**, and **Heberden's nodes** are found on the **DIP joints**. *Palm and DIP* - This option incorrectly identifies the palm as a site for node formation in osteoarthritis. - Osteoarthritis typically affects the **interphalangeal joints** (PIP and DIP) and not the palmar aspect of the hand.

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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