Rheumatology and Immunology — MCQs

A 44-year-old businessman presents with a markedly inflamed and painful right great toe. He reports increasing pain in his right foot during a recent plane trip. Physical examination reveals swelling and erythema of the right great toe, along with small nodules on his external ears. Aspiration of the metatarsophalangeal joint of the affected toe shows needle-shaped, negatively birefringent crystals. Which of the following agents would provide the most immediate relief for this patient?

Q84Hard

A 23-year-old man presents with gradual and progressive dyspnea. He has a long history of back pain with prolonged morning stiffness and a past episode of iritis. Physical examination reveals reduced lumbar spine mobility with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissues. Pelvic X-rays show sacroiliac joint erosions and sclerosis. What is the most likely pulmonary complication associated with this condition?

Q85Easy

The 'Pathergy Test' is specific for which of the following conditions?

Q86Medium

Which of the following is NOT an extra-articular manifestation of ankylosing spondylitis?

Q87Easy

Which of the following are diagnostic criteria for Systemic Lupus Erythematosus?

Q88Medium

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

Q89Medium

Which vasculitis affects both the arterial and venous systems?

Q90Medium

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?

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 81: What is the most specific diagnostic finding in gout?

A. Uric acid crystals in urine
B. Raised serum uric acid
C. Presence of calcium pyrophosphate crystals in synovial fluid
D. Presence of monosodium urate crystals in synovial fluid (Correct Answer)

Explanation: **Explanation:** The **gold standard** and most specific diagnostic finding for gout is the identification of **monosodium urate (MSU) crystals** [1] [2] in synovial fluid or tophus aspirate. Under compensated polarized light microscopy, these crystals are characteristically **needle-shaped** and exhibit **strong negative birefringence** [2] (appearing yellow when aligned parallel to the slow axis of the compensator). **Analysis of Options:** * **Option A (Uric acid crystals in urine):** These are common in acidic urine and may indicate a risk for urolithiasis, but they are not diagnostic of gouty arthritis [3]. * **Option B (Raised serum uric acid):** While hyperuricemia is the metabolic hallmark of gout, it is **neither sensitive nor specific** [3]. Many patients with hyperuricemia never develop gout, and conversely, serum uric acid levels can be normal or low during an acute gouty attack (due to cytokines increasing renal excretion). * **Option C (Calcium pyrophosphate crystals):** These are the hallmark of **Pseudogout** (CPPD) [2]. They are rhomboid-shaped and show weak positive birefringence. **High-Yield Clinical Pearls for NEET-PG:** * **First-line treatment for acute gout:** NSAIDs (e.g., Indomethacin), Colchicine, or Corticosteroids. * **Definitive Diagnosis:** Polarized microscopy of joint aspirate. * **Radiological Sign:** "Punched-out" erosions with overhanging edges (**Martel’s sign**) are seen in chronic gout. * **Drug of Choice for Chronic Gout:** Allopurinol (Xanthine oxidase inhibitor) [2], but it should **never** be started during an acute attack as it may worsen the flare.

Question 82: Which structure involvement is uncommon in Churg-Strauss syndrome?

A. Skin
B. Lungs
C. Kidney (Correct Answer)
D. Peripheral nerve

Explanation: Churg-Strauss Syndrome (now known as **Eosinophilic Granulomatosis with Polyangiitis - EGPA**) is a small-vessel necrotizing vasculitis characterized by asthma, peripheral blood eosinophilia, and extravascular granulomas. **Why Kidney is the correct answer:** While EGPA is a systemic vasculitis, **renal involvement is relatively uncommon** (occurring in approximately 25% of cases) compared to other ANCA-associated vasculitides like Granulomatosis with Polyangiitis (GPA) or Microscopic Polyangiitis (MPA). When it does occur, it typically manifests as focal segmental necrotizing glomerulonephritis [2], but it is rarely the dominant or presenting feature. **Why other options are incorrect:** * **Lungs (Option B):** The lung is the **most commonly involved organ**. Asthma is the hallmark of EGPA, often preceding the vasculitic phase by years. Pulmonary infiltrates are frequent [1]. * **Peripheral Nerve (Option D):** Neurologic involvement is very common (up to 75% of cases), most typically presenting as **mononeuritis multiplex** (e.g., foot drop/wrist drop) [1]. * **Skin (Option A):** Cutaneous manifestations like palpable purpura, nodules, or urticaria are seen in about 50-60% of patients [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of EGPA:** Asthma + Hypereosinophilia (>1500 cells/µL) + Vasculitis [1]. * **ANCA Status:** Only about 40-50% of patients are **p-ANCA (anti-MPO) positive** [1]. p-ANCA positivity is more strongly associated with renal disease and alveolar hemorrhage. * **Cardiac Involvement:** This is the **leading cause of mortality** in EGPA (myocarditis/coronary vasculitis) [1]. * **Treatment:** Corticosteroids are the mainstay; Cyclophosphamide is added for severe organ involvement (Five-Factor Score) [1].

Question 83: A 44-year-old businessman presents with a markedly inflamed and painful right great toe. He reports increasing pain in his right foot during a recent plane trip. Physical examination reveals swelling and erythema of the right great toe, along with small nodules on his external ears. Aspiration of the metatarsophalangeal joint of the affected toe shows needle-shaped, negatively birefringent crystals. Which of the following agents would provide the most immediate relief for this patient?

A. Allopurinol
B. Aspirin
C. Colchicine (Correct Answer)
D. Probenecid

Explanation: ### Explanation **Correct Option: C. Colchicine** This patient presents with a classic case of **Acute Gouty Arthritis** (Podagra), triggered by dehydration during a flight [3]. The diagnosis is confirmed by the presence of **tophi** (nodules on the ear) [2] and the pathognomonic finding of **needle-shaped, negatively birefringent monosodium urate (MSU) crystals** under polarized light microscopy. **Why Colchicine is correct:** In an acute gouty attack, the goal is to reduce inflammation rapidly. **Colchicine** works by inhibiting microtubule polymerization (binding to tubulin), which prevents leukocyte migration and phagocytosis of urate crystals, thereby providing immediate symptomatic relief. Other first-line agents include NSAIDs (e.g., Indomethacin) and Corticosteroids. **Why other options are incorrect:** * **A. Allopurinol:** This is a Xanthine Oxidase inhibitor used for **chronic** management (urate-lowering therapy) [1]. Starting it during an acute attack can worsen the inflammation by causing rapid fluctuations in serum urate levels, leading to further crystal mobilization [1]. * **B. Aspirin:** Low-dose aspirin is contraindicated in gout because it inhibits the renal excretion of uric acid (via OAT transporters), potentially worsening hyperuricemia. * **D. Probenecid:** This is a uricosuric agent used for chronic gout in patients with underexcretion of uric acid [1]. Like Allopurinol, it has no role in managing acute inflammation. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard Diagnosis:** Polarized light microscopy showing **negative birefringence** (crystals appear yellow when parallel to the slow axis). * **Radiology:** Look for

Question 84: A 23-year-old man presents with gradual and progressive dyspnea. He has a long history of back pain with prolonged morning stiffness and a past episode of iritis. Physical examination reveals reduced lumbar spine mobility with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissues. Pelvic X-rays show sacroiliac joint erosions and sclerosis. What is the most likely pulmonary complication associated with this condition?

A. Upper lobe fibrosis (Correct Answer)
B. Airflow obstruction
C. Chronic pulmonary embolism
D. Pleural effusions

Explanation: **Explanation:** The clinical presentation of chronic back pain with morning stiffness, history of iritis, reduced lumbar mobility, and sacroiliac joint sclerosis in a young male is diagnostic of **Ankylosing Spondylitis (AS)** [1]. **1. Why Option A is correct:** While the most common pulmonary finding in AS is actually a **restrictive lung pattern** due to chest wall restriction (costovertebral joint involvement), the most characteristic and "classic" parenchymal complication is **apical (upper lobe) fibrocystic disease**. This typically manifests as bilateral, symmetric upper lobe fibrosis and cavitation, which can mimic tuberculosis. These cavities may become colonized by *Aspergillus*, leading to mycetoma formation. **2. Why the other options are incorrect:** * **B. Airflow obstruction:** AS primarily causes restrictive lung disease, not obstructive. Airflow is usually preserved unless the patient has a co-existing condition like COPD. * **C. Chronic pulmonary embolism:** There is no direct association between AS and chronic PE. * **D. Pleural effusions:** While pleuritis can rarely occur in AS, it is much more characteristic of Systemic Lupus Erythematosus (SLE) or Rheumatoid Arthritis (RA). **Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated with AS (>90% of cases) [1]. * **Schober’s Test:** Used to assess restricted lumbar flexion. * **Bamboo Spine:** Late-stage radiographic finding due to syndesmophyte formation and ligamentous calcification [1]. * **Extra-articular manifestations:** Acute anterior uveitis (most common), Aortitis/Aortic regurgitation, and Apical lung fibrosis [1]. * **Treatment:** NSAIDs are first-line; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Question 85: The 'Pathergy Test' is specific for which of the following conditions?

A. Caplan's syndrome
B. Sjogren's syndrome
C. Behcet's syndrome (Correct Answer)
D. Felty's syndrome

Explanation: **Explanation:** The **Pathergy Test** is a diagnostic tool used to identify cutaneous hypersensitivity to minor trauma. It is a hallmark clinical feature and a highly specific diagnostic criterion for **Behcet’s Syndrome**. **1. Why Behcet’s Syndrome is correct:** Behcet’s is a multi-system, chronic relapsing vasculitis. The pathergy phenomenon occurs due to an exaggerated inflammatory response by neutrophils to a local insult. * **Procedure:** A sterile 20-gauge needle is pricked into the skin (usually the forearm). * **Positive Result:** Formation of a sterile erythematous papule or pustule (>2mm) at the site of the prick within 24–48 hours. * **Significance:** While highly specific for Behcet's, the test's sensitivity varies geographically (highest in Silk Road populations). **2. Why other options are incorrect:** * **Caplan’s Syndrome:** This is the combination of Rheumatoid Arthritis (RA) and Coal Workers' Pneumoconiosis, characterized by intrapulmonary nodules. * **Sjogren’s Syndrome:** An autoimmune destruction of exocrine glands (lacrimal/salivary). Diagnosis relies on the Schirmer’s test, anti-Ro/SSA, and anti-La/SSB antibodies [1]. * **Felty’s Syndrome:** A triad of Rheumatoid Arthritis, Splenomegaly, and Neutropenia. It does not involve skin hypersensitivity. **Clinical Pearls for NEET-PG:** * **Behcet’s Triad:** Recurrent oral ulcers (most common), genital ulcers (most specific), and uveitis. * **HLA Association:** Strongly linked with **HLA-B51**. * **Other Pathergy-positive conditions:** Pyoderma Gangrenosum and Sweet’s Syndrome (Neutrophilic dermatosis) can also show pathergy, but in the context of systemic vasculitis questions, Behcet’s is the primary answer. * **Treatment:** Colchicine is often the first-line agent for mucocutaneous symptoms. [Note: Provided references discussed Sjögren's antibodies but did not contain specific text for Behcet's Syndrome pathergy dynamics].

Question 86: Which of the following is NOT an extra-articular manifestation of ankylosing spondylitis?

A. Acute anterior uveitis
B. Aortic valve disease
C. Pulmonary fibrosis
D. Dilated cardiomyopathy (Correct Answer)

Explanation: Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton but is frequently associated with specific systemic extra-articular manifestations [1]. **Why Option D is Correct:** While AS is associated with cardiovascular complications, the classic involvement is **Aortitis** and **Aortic Root Dilatation**, which leads to **Aortic Regurgitation** and conduction defects (like AV blocks). **Dilated Cardiomyopathy (DCM)** is not a recognized or typical feature of AS. If heart failure occurs in AS patients, it is usually secondary to valvular disease or long-standing conduction issues, rather than a primary dilated cardiomyopathic process. **Analysis of Incorrect Options:** * **A. Acute Anterior Uveitis:** This is the **most common** extra-articular manifestation (seen in ~40% of patients) [1]. It is typically unilateral, presents with pain, redness, and photophobia, and is strongly associated with HLA-B27 [1]. * **B. Aortic Valve Disease:** Inflammation of the aortic root can lead to thickening of the valve cusps and dilatation of the annulus, resulting in **Aortic Regurgitation**. * **C. Pulmonary Fibrosis:** AS is associated with **apical (upper lobe) fibrocystic disease**. This is often bilateral and can be complicated by secondary *Aspergillus* colonization (mycetoma). **NEET-PG High-Yield Pearls:** * **Mnemonic for AS manifestations (6 A’s):** **A**pical fibrosis, **A**nterior uveitis, **A**ortic regurgitation, **A**chilles tendonitis (enthesitis), **A**myloidosis (secondary), and **A**tlanto-axial subluxation. * **Respiratory:** The most common pulmonary finding is actually **restrictive lung disease** due to chest wall rigidity (costovertebral joint involvement), not the fibrosis itself. * **Renal:** Secondary **AA Amyloidosis** is a rare but serious late complication leading to nephrotic syndrome.

Question 87: Which of the following are diagnostic criteria for Systemic Lupus Erythematosus?

A. Antinuclear Antibody (ANA)
B. Anti double-stranded DNA (anti-dsDNA) antibodies
C. Proteinuria greater than 500 mg/day
D. All of the above (Correct Answer)

Explanation: **Explanation:** Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease characterized by the production of various autoantibodies. To standardize diagnosis, clinicians primarily use the **SLICC (2012)** or the **ACR/EULAR (2019)** criteria. 1. **Antinuclear Antibody (ANA):** This is the **entry criterion** for the 2019 ACR/EULAR classification [1]. It is highly sensitive (approx. 95-99%), meaning a negative ANA makes a diagnosis of SLE highly unlikely [1]. 2. **Anti-dsDNA Antibodies:** These are highly specific for SLE and are part of the immunologic criteria [1]. Their levels often correlate with disease activity, particularly lupus nephritis [1]. 3. **Proteinuria > 500 mg/24h:** Renal involvement is a hallmark of SLE. The presence of persistent proteinuria (>0.5g/day) or cellular casts (red cell casts) fulfills a clinical criterion for diagnosis [1]. **Why "All of the above" is correct:** Since SLE is a "great imitator," diagnosis requires a combination of clinical features (like malar rash, arthritis, or proteinuria) and laboratory findings (like ANA and anti-dsDNA). All three options listed are recognized components of the diagnostic frameworks. **High-Yield Clinical Pearls for NEET-PG:** * **Most Sensitive Test:** ANA (Best screening test) [1]. * **Most Specific Tests:** Anti-dsDNA and Anti-Smith (Anti-Sm) antibodies [1]. * **Drug-Induced Lupus:** Associated with **Anti-Histone** antibodies; usually spares the kidney and CNS. * **Complement Levels:** Low C3 and C4 levels are often seen during active flares, especially in renal disease [1]. * **Libman-Sacks Endocarditis:** A classic cardiac manifestation (non-bacterial verrucous vegetations).

Question 88: A patient presents with musculoskeletal complaints. What feature is suggestive of a non-articular origin of pain?

A. Pain or decreased range of motion on both active and passive movement
B. Swelling
C. Crepitation
D. Pain on active movement but not on passive movement (Correct Answer)

Explanation: To distinguish between **articular** (joint) and **non-articular** (periarticular) pain, clinicians must evaluate the structures involved [1]. Articular disorders involve the joint capsule, synovium, and cartilage, while non-articular disorders involve tendons, ligaments, bursae, or muscle. ### **Explanation of the Correct Answer** **D. Pain on active movement but not on passive movement:** This is the hallmark of non-articular pain. In non-articular structures (like a tendon), **active** movement causes pain because it requires the contraction of the muscle-tendon unit [1]. However, **passive** movement (where the examiner moves the limb while the patient relaxes) does not stress the specific non-articular structure, resulting in a normal range of motion without significant pain. ### **Analysis of Incorrect Options** * **A. Pain/decreased ROM on both active and passive movement:** This is characteristic of **articular** disease. When the joint itself is inflamed or damaged, any movement—whether initiated by the patient or the examiner—stresses the joint capsule and synovium, leading to pain and restricted motion in all planes [2]. * **B. Swelling:** While soft tissue swelling can occur in non-articular conditions (e.g., bursitis), true **intra-articular swelling** (effusion) is a classic sign of joint pathology [2]. * **C. Crepitation:** This refers to a grating or crackling sound/sensation produced by the friction of bone on bone or irregular cartilage. It is a definitive sign of **articular** damage, commonly seen in osteoarthritis [2]. ### **High-Yield Clinical Pearls for NEET-PG** * **Articular Pain:** Characterized by deep/diffuse pain, limited range of motion in both active and passive movements, and "locking" or "instability." * **Non-articular Pain:** Characterized by point tenderness, pain that is often reproducible by specific resisted movements, and preserved passive range of motion [1]. * **Key Example:** In **Rotator Cuff Tendonitis** (non-articular), the patient has pain on active abduction but full passive range of motion [1]. In **Adhesive Capsulitis** (articular), both active and passive ranges of motion are restricted.

Question 89: Which vasculitis affects both the arterial and venous systems?

A. Wegener's granulomatosis (Correct Answer)
B. Polyarteritis nodosa (PAN)
C. Behçet's disease
D. Kawasaki disease

Explanation: The correct answer is **Wegener's granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA). While most vasculitides are classified based on the size of the *arteries* they affect, GPA is unique because it involves both the **arterial and venous systems**. Pathologically, it is characterized by necrotizing granulomatous inflammation of the upper and lower respiratory tracts and necrotizing glomerulonephritis [1]. The venous involvement often manifests as a significantly increased risk of venous thromboembolism (VTE), such as DVT or pulmonary embolism, during active disease. [1] **Analysis of Incorrect Options:** * **Polyarteritis nodosa (PAN):** This is a systemic necrotizing vasculitis that typically affects **medium-sized and small muscular arteries**. A hallmark of PAN is that it characteristically **spares the venous system** and the pulmonary arteries. * **Behçet's disease:** While Behçet’s is famous for involving both arteries and veins (often causing venous thrombosis and pulmonary artery aneurysms), in the context of standard NEET-PG curriculum and classic vasculitis classification, GPA is the preferred answer when discussing systemic small-vessel vasculitis involving both systems. *Note: If GPA were not an option, Behçet’s would be a strong contender.* * **Kawasaki disease:** This is a medium-vessel vasculitis primarily affecting children, with a predilection for the **coronary arteries**. It does not typically involve the venous system. **High-Yield Clinical Pearls for NEET-PG:** * **GPA Triad:** Upper respiratory tract (sinusitis/saddle nose), Lower respiratory tract (hemoptysis/cavitation), and Kidneys (RPGN). * **Serology:** GPA is strongly associated with **c-ANCA (anti-PR3)**. * **Treatment:** Induction with Cyclophosphamide or Rituximab plus Corticosteroids. * **Key Distinction:** Unlike PAN, GPA involves the lungs and the venous system.

Question 90: 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?

A. ASCA Ab, ANCA Ab, and Anti-histone Ab
B. ASCA Ab, Ab against ALPHA-ENOLASE, and Anti-histone Ab
C. ASCA Ab, Ab against ALPHA-ENOLASE, and Ab against selenium binding protein (Correct Answer)
D. ANCA Ab, Ab against ALPHA-ENOLASE, and Ab against selenium binding protein

Explanation: ### **Explanation** The clinical presentation of **recurrent oral aphthous ulcers, genital ulcers, skin lesions (pseudofolliculitis/erythema nodosum), and panuveitis** in a young male is diagnostic of **Behçet’s Disease**. The "test" mentioned (intradermal saline injection) refers to the **Pathergy Test**, which is highly specific for this condition. #### **1. Why Option C is Correct** Behçet’s Disease is a systemic variable-vessel vasculitis. While diagnosis is primarily clinical (International Study Group criteria), specific antibodies are frequently associated: * **Anti-Saccharomyces cerevisiae antibodies (ASCA):** Found in about 18-50% of Behçet’s patients, particularly those with gastrointestinal involvement (mimicking Crohn’s). * **Anti-Alpha-Enolase Antibodies:** These are markers of endothelial cell activation and damage, common in vasculitides like Behçet’s. * **Anti-Selenium Binding Protein (SBP) Antibodies:** These are highly specific markers recently identified in Behçet’s patients, especially those with ocular involvement (uveitis). #### **2. Why Other Options are Incorrect** * **Options A & B:** Mention **Anti-histone antibodies**, which are characteristic of **Drug-Induced Lupus (DILE)**, not Behçet’s. * **Options A & D:** Mention **ANCA (Anti-Neutrophil Cytoplasmic Antibodies)**. Behçet’s is typically **ANCA-negative**, distinguishing it from small-vessel vasculitides like GPA or MPA. #### **3. Clinical Pearls for NEET-PG** * **HLA Association:** Strongly associated with **HLA-B51**. * **Pathergy Test:** Development of a papule or pustule 24–48 hours after a sterile needle prick. * **Ocular Involvement:** Panuveitis and retinal vasculitis are the most dreaded complications, often leading to blindness if untreated. * **Vascular Involvement:** Unique among vasculitides for causing both **arterial aneurysms** and **venous thrombosis** (e.g., Budd-Chiari syndrome). * **Treatment:** Colchicine for mucocutaneous lesions; Azathioprine or Anti-TNF agents (Infliximab) for ocular/systemic disease.

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

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Crystal Arthropathies

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Osteoarthritis

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Primary Immunodeficiency Disorders

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Autoinflammatory Syndromes

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Sjögren's Syndrome

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Antiphospholipid Syndrome

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