Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 881: Which joint is most commonly affected in pseudogout?

A. Knee (Correct Answer)
B. Hip
C. MP joint great toe
D. MP joint thumb

Explanation: ***Knee*** - The **knee joint** is the most frequent site of acute attacks and chronic arthropathy in pseudogout due to the propensity for **calcium pyrophosphate dihydrate (CPPD)** crystal deposition in larger joints [1]. - Patients often present with acute, painful, and swollen knees, sometimes mimicking septic arthritis or gout [1]. *Hip* - While hip involvement can occur in pseudogout, it is **less common** than knee involvement and often manifests as chronic degenerative changes. - Acute hip flares are rarer compared to the knee. *MP joint great toe* - The **metatarsaophalangeal (MTP) joint of the great toe** is the classic site for **gout**, caused by monosodium urate crystal deposition. - Although pseudogout can affect various joints, this specific location is strongly indicative of gout, not pseudogout. *MP joint thumb* - The **metacarpophalangeal (MCP) joint of the thumb** can be affected in various arthropathies, but it is not the most commonly affected joint in pseudogout. - Involvement here is less specific for pseudogout compared to the knee.

Question 882: The most likely diagnosis in the case of a patient with multiple pulmonary cavities, hematuria, and red cell casts is?

A. Anti-GBM disease
B. Churg-Strauss
C. Systemic lupus erythematousus
D. Wegener's granulomatosis (Correct Answer)

Explanation: ***Wegener's granulomatosis (Granulomatosis with Polyangiitis)*** - This condition classically presents with a **triad of upper airway, lower airway, and renal involvement** [1]. **Pulmonary cavities** represent severe lung involvement, and **hematuria with red cell casts** indicate rapidly progressive glomerulonephritis [3]. - It is an **ANCA-associated vasculitis**, specifically associated with **c-ANCA (anti-PR3 antibodies)**, and often leads to **granulomatous inflammation** [1], [3]. *Anti-GBM disease* - Characterized by **glomerulonephritis** and **pulmonary hemorrhage** (Goodpasture's syndrome) [1], but does not typically cause multiple **pulmonary cavities**. - Diagnosed by the presence of **anti-glomerular basement membrane antibodies** and linear IgG deposition on renal biopsy [1]. *Churg-Strauss* - This condition, now known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, is characterized by **asthma, eosinophilia, and vasculitis** [1]. - While it can affect the lungs and kidneys, **pulmonary cavities** are less common, and severe eosinophilia is a hallmark, which is not mentioned here [1]. *Systemic lupus erythematosus* - A multisystem autoimmune disease that can cause **glomerulonephritis (lupus nephritis)** and pleuropulmonary involvement [2]. - However, **multiple pulmonary cavities** are not a typical manifestation, and other classic lupus features (e.g., malar rash, arthralgias) are absent in the description [2].

Question 883: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?

A. Acute interstitial nephritis
B. Poststreptococcal glomerulonephritis
C. Lupus nephritis (Correct Answer)
D. IgA nephropathy

Explanation: ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.

Question 884: A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

A. Osteoarthritis (Correct Answer)
B. Rheumatoid arthritis
C. Psoriatic arthritis
D. Gout

Explanation: ***Osteoarthritis*** - **Osteoarthritis** typically affects the **1st carpometacarpal (CMC)* joint (of which the 1st MCP is a part), **proximal interphalangeal (PIP)**, and **distal interphalangeal (DIP)** joints, consistent with the patient's presentation [1]. - It classically **spares the wrist and ankle joints** in its early stages, supporting this diagnosis. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints symmetrically, but typically **spares the distal interphalangeal (DIP) joints** [1]. - It frequently involves the **wrist and ankle joints**, which are noted as spared in this case [1]. *Psoriatic arthritis* - **Psoriatic arthritis** can affect DIP joints and may present with different patterns, but a classic presentation often includes **dactylitis** (sausage digits) or nail changes, which are not mentioned [1]. - While it can affect the hand joints, the specific pattern described, including the sparing of the wrist and ankle, is not its most typical presentation. *Gout* - **Gout** is characterized by acute, severe pain, typically in a single joint, with the **first metatarsophalangeal (MTP) joint** (of the big toe) being most commonly affected, known as podagra. - While gout can affect other joints, its episodic nature and acute inflammatory presentation differ from the chronic, progressive pattern suggested by the question.

Question 885: Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

A. Patients with PAN may exhibit hypergammaglobulinemia.
B. Approximately 30% of patients with Polyarteritis Nodosa (PAN) are HBsAg positive.
C. ANCA is typically negative in PAN. (Correct Answer)
D. Microscopy shows fibrinoid necrosis in medium-sized arteries

Explanation: ***30% of people have HbsAg positive*** - Hepatitis B virus infection is associated with **polyarteritis nodosa (PAN)**, with **30%** of patients having a positive **HbsAg**. - The presence of **HbsAg** indicates active Hepatitis B, which can lead to vasculitis seen in PAN. *Microscopy shows fibrinoid necrosis in large arteries* - While fibrinoid necrosis is present in vasculitides [1], it is more characteristic of **granulomatosis with polyangiitis** (Wegener's) rather than PAN. - PAN typically shows **intranuclear inclusions** and necrotizing vasculitis without predominant fibrinoid necrosis. *Patient have hypogammaglobulinemia* - Patients with PAN do not typically present with **hypogammaglobulinemia**; rather, they may have normal immunoglobulin levels. - Hypogammaglobulinemia is more commonly associated with other types of vasculitis, such as **SLE** or **chronic infections**. *ANCA is positive* - Perinuclear anti-neutrophil cytoplasmic antibodies (**ANCA**) are usually associated with **granulomatosis and eosinophilic granulomatosis** rather than PAN. - PAN is **ANCA-negative** and is characterized by alternate antibodies, particularly if associated with Hepatitis B.

Question 886: Sausage finger appearance is associated with which of the following conditions?

A. Rickets
B. Hyperthyroidism
C. Addison's disease
D. Psoriatic arthritis (Correct Answer)

Explanation: ***Psoriatic arthritis*** - **Dactylitis**, or "sausage finger," is a characteristic inflammatory finding in psoriatic arthritis, resulting from inflammation of the **entire digit** [1]. - This condition involves inflammation of tendons, joints, and soft tissues which leads to diffuse swelling of fingers or toes [1]. *Rickets* - Rickets is a bone-softening disease in children caused by **vitamin D deficiency**, leading to bone deformities like bowed legs or widened wrists. - It does not present with inflammatory dactylitis or "sausage digits." *Hyperthyroidism* - Hyperthyroidism is a condition of excessive thyroid hormone production, which can cause symptoms like **tremors**, **tachycardia**, and **weight loss** [2]. - It is not associated with dactylitis or changes in finger morphology. *Addison's disease* - Addison's disease results from **adrenal insufficiency**, leading to symptoms like **fatigue**, **skin hyperpigmentation**, and hypotension. - There is no clinical association between Addison's disease and "sausage finger" appearance.

Question 887: Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

A. Generalized joint pain and swelling
B. Morning stiffness lasting more than 30 minutes
C. Presence of rheumatoid factor (RF) (Correct Answer)
D. Joint deformities

Explanation: Presence of rheumatoid factor (RF) - **Seropositive rheumatoid arthritis** is specifically defined by the presence of **rheumatoid factor (RF)** or anti-citrullinated protein antibodies (anti-CCP), indicating a particular immunological subtype of the disease [1]. - The detection of **RF**, an autoantibody, is a key diagnostic marker that helps differentiate seropositive RA from seronegative forms and other inflammatory arthritides [1]. Joint deformities - Joint deformities, such as **ulnar deviation** or **boutonnière and swan neck deformities**, are a common *consequence* of chronic, uncontrolled rheumatoid arthritis [2]. - While characteristic of advanced disease, deformities are not a *defining feature* for the initial classification of **seropositive RA**, which is based on serological markers. Morning stiffness lasting more than 30 minutes - **Morning stiffness** that persists for more than 30 minutes is a classic *symptom* of inflammatory arthritis, including both seropositive and seronegative RA [3]. - Although it is an important diagnostic criterion for RA in general, it is not specific to the **seropositive subtype** because it can be present in other inflammatory arthropathies as well [3]. Generalized joint pain and swelling - **Generalized joint pain and swelling**, typically in a symmetrical pattern affecting small joints, are core *symptoms* of rheumatoid arthritis and indicate active inflammation [3]. - These symptoms are common in all forms of RA, including both seropositive and seronegative, and thus do not specifically characterize the **seropositive subtype**.

Question 888: Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

A. ANCA (Correct Answer)
B. RA factor
C. Hbsag
D. MIF

Explanation: ### ANCA - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points towards a small-vessel vasculitis, for which **ANCA (anti-neutrophil cytoplasmic antibodies)** testing is crucial [1]. - ANCA is highly specific for conditions like **Granulomatosis with Polyangiitis (GPA)** and **Microscopic Polyangiitis (MPA)** [1]. ### RA factor - **Rheumatoid factor (RF)** is primarily associated with **rheumatoid arthritis**, which typically presents with symmetrical polyarthritis, not the constellation of symptoms described. - While RF can be positive in some vasculitides, it is not the most specific initial test for the given clinical presentation. ### Hbsag - **Hepatitis B surface antigen (HbsAg)** typically screens for **Hepatitis B infection**, which can cause **polyarteritis nodosa (PAN)**, a medium-vessel vasculitis. - However, the patient's symptoms (cutaneous vasculitis, glomerulonephritis) are more characteristic of **small-vessel vasculitis**, making ANCA a more direct investigation [1]. ### MIF - **MIF (Macrophage Migration Inhibitory Factor)** is a cytokine involved in inflammation, but it is not a routine diagnostic marker for vasculitis. - It is not used as a primary investigation to diagnose specific autoimmune or inflammatory conditions like vasculitis.

Question 889: In long standing rheumatoid arthritis, which condition is commonly observed?

A. Milk alkali syndrome
B. Nephrolithiasis
C. Paradoxical aciduria
D. Secondary amyloidosis (Correct Answer)

Explanation: ***Secondary amyloidosis*** - Chronic inflammation in **rheumatoid arthritis** can lead to the production and deposition of **amyloid A protein**, which is the hallmark of secondary (AA) amyloidosis [1]. - **Secondary amyloidosis** can affect various organs, including the kidneys, heart, and gastrointestinal tract, leading to organ dysfunction [1]. *Milk alkali syndrome* - This condition is caused by excessive intake of **calcium** and absorbable alkali, resulting in **hypercalcemia** and **metabolic alkalosis**. - It is not directly associated with the chronic inflammatory process of rheumatoid arthritis. *Nephrolithiasis* - **Kidney stones** (nephrolithiasis) are often associated with genetic predispositions, dietary factors, and certain metabolic conditions like **hypercalciuria** or **hyperoxaluria**. - There is no direct causal link between **rheumatoid arthritis** and an increased risk of common types of kidney stones. *Paradoxical aciduria* - This condition is characterized by the excretion of acidic urine in the presence of **metabolic alkalosis**, typically due to **volume depletion** and **hypokalemia**. - While it reflects a disturbance in acid-base balance and renal function, it is not a direct or commonly observed complication of long-standing rheumatoid arthritis itself.

Question 890: A 23-year old woman has experienced episodes of myalgias, pleural effusion, pericarditis and arthralgias without joint deformity over course of several years. The best laboratory screening test to diagnose her disease would be -

A. Erythrocyte sedimentation rate
B. Antinuclear antibody (Correct Answer)
C. Assay for thyroid hormones
D. CD4/CD8 lymphocyte count

Explanation: ***Antinuclear antibody*** - The constellation of **myalgias**, **pleural effusion**, **pericarditis**, and **arthralgias without joint deformity** is highly suggestive of **systemic lupus erythematosus (SLE)**. - **Antinuclear antibodies (ANA)** are present in over 95% of patients with SLE and are the primary screening test for this condition [1]. *CD4/CD8 lymphocyte count* - This count is more relevant for monitoring **immunodeficiency** conditions like **HIV infection**, where it helps assess immune status. - While lymphocytes can be affected in autoimmune diseases, a CD4/CD8 count is not a primary screening test for SLE. *Erythrocyte sedimentation rate* - An **elevated ESR** indicates general inflammation and is a **non-specific marker** [2]. - While it is often elevated in SLE, it doesn't confirm the diagnosis and can be high in numerous other inflammatory conditions [1]. *Assay for thyroid hormones* - An assay for thyroid hormones is used to diagnose **thyroid disorders** like **hypothyroidism** or **hyperthyroidism**. - There is no direct link between thyroid hormone levels and the symptoms described in the patient.

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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