Vasculitis — MCQs
A male child presented with arthralgia and abdominal pain. On examination, there was palpable purpura over the lower limbs. There is a past history of upper respiratory tract infection prior to the onset of presenting symptoms. Which of the following is the treatment for this condition?
Fibrinoid necrosis with neutrophilic infiltration is seen in ?
A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?
Which feature best differentiates ANCA-associated vasculitis from anti-GBM disease?
A 12-year-old boy presents with weak pulses in the upper limbs, a blood pressure of 90/60 mmHg , and retinal hemorrhages. What is the most likely diagnosis?
A patient presents with cutaneous vasculitis, glomerulonephritis and peripheral neuropathy. What investigation is to be performed next for work up?
A 30-year-old construction worker had a partial traumatic nail avulsion. 3 weeks later he presents with the presentation shown below. What is the diagnosis?
Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?
Allen's test is used to diagnose which condition?
What is the preferred material for femoro-popliteal bypass?
Vasculitis Indian Medical PG Practice Questions and MCQs
Question 1: A male child presented with arthralgia and abdominal pain. On examination, there was palpable purpura over the lower limbs. There is a past history of upper respiratory tract infection prior to the onset of presenting symptoms. Which of the following is the treatment for this condition?
- A. Azathioprine
- B. Methotrexate
- C. Cyclosporine
- D. Glucocorticoids (Correct Answer)
Explanation: ***Glucocorticoids*** - The constellation of **arthralgia**, **abdominal pain**, and **palpable purpura** following an **upper respiratory tract infection** in a child is highly suggestive of **Henoch-Schönlein purpura (HSP)**, now known as **IgA vasculitis**. - **Glucocorticoids** are indicated in HSP for severe symptoms like significant abdominal pain, gastrointestinal bleeding, or painful arthralgia, all of which this patient demonstrates. - While HSP often resolves spontaneously with supportive care, this patient's presentation with both arthralgia and abdominal pain warrants glucocorticoid therapy. *Azathioprine* - **Azathioprine** is an immunosuppressant typically used for conditions like rheumatoid arthritis, IBD, or organ transplant rejection. - It is not a first-line treatment for the acute management of **IgA vasculitis**, which typically responds to supportive care or short courses of steroids for severe symptoms. *Methotrexate* - **Methotrexate** is a disease-modifying antirheumatic drug (DMARD) used in conditions such as rheumatoid arthritis, psoriasis, and certain cancers. - It does not have a role in the acute treatment of uncomplicated **IgA vasculitis** based on the described symptoms. *Cyclosporine* - **Cyclosporine** is a potent immunosuppressant used in severe autoimmune conditions or to prevent organ rejection. - While it may be considered in very severe, refractory cases of **IgA vasculitis** with significant renal involvement, it is not the initial treatment for the symptoms presented.
Question 2: Fibrinoid necrosis with neutrophilic infiltration is seen in ?
- A. Polyarteritis Nodosa (PAN) (Correct Answer)
- B. Giant Cell Arteritis
- C. Takayasu Arteritis
- D. Wegener's Granulomatosis
Explanation: ***PAN*** - **Fibrinoid necrosis** with **neutrophilic infiltration** is characteristic of Polyarteritis Nodosa (PAN), which primarily affects medium-sized arteries [1]. - The necrosis is often seen in the context of **systemic vasculitis**, where it leads to damage and inflammation of vessel walls [3]. *Takayasu arteritis* - Primarily affects **large vessels** like the aorta and its major branches, typically presenting with **pulselessness** or **claudication**. - It shows **granulomatous inflammation** rather than fibrinoid necrosis with neutrophilic infiltration. *Giant cell arteritis* - Predominantly affects large and medium arteries, especially the **temporal artery**, often leading to headaches and visual disturbances. - It is associated with **giant cells** and lymphocytic infiltration rather than fibrinoid necrosis. *Wegener's granulomatosis* - Characterized by **granulomatous inflammation** and vasculitis affecting small to medium vessels, particularly in the lungs and kidneys. - It does not typically present with **fibrinoid necrosis**; instead, it shows necrotizing granulomas [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 518-519. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 687-688.
Question 3: A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?
- A. Giant cell arteritis (Correct Answer)
- B. Wegener's granulomatosis
- C. Microscopic polyangiitis
- D. Takayasu arteritis
Explanation: ***Giant cell arteritis*** - This presentation with **severe headache**, **temporal artery tenderness**, and a **decreased pulse** in a 65-year-old patient is highly classic for giant cell arteritis (GCA). GCA characteristically affects **medium and large arteries**, often the **temporal artery**. - **Decreased pulse** can indicate involvement of other large vessels, such as the subclavian artery, which can occur in GCA. Urgent diagnosis and treatment are crucial due to the risk of **permanent vision loss** [1]. *Wegener's granulomatosis* - This condition (**granulomatosis with polyangiitis**) is characterized by **upper and lower respiratory tract granulomatous inflammation**, **glomerulonephritis**, and small vessel vasculitis. - While it can manifest with systemic symptoms, **temporal artery tenderness** and a **decreased pulse** are not primary features of Wegener's. *Microscopic polyangiitis* - This is a **small vessel vasculitis** that primarily affects capillaries, venules, and arterioles. - It typically presents with **glomerulonephritis** and **pulmonary capillaritis**, but without granuloma formation, and does not involve the temporal arteries or lead to a decreased pulse in the manner described. *Takayasu arteritis* - Takayasu arteritis primarily affects the **aorta and its major branches**, leading to **claudication**, **pulse deficits** in the extremities, and often occurs in **younger women**. - While it can cause a decreased pulse, it is less likely to present with **temporal artery tenderness** and severe headache in a 65-year-old, as these symptoms are more characteristic of GCA.
Question 4: Which feature best differentiates ANCA-associated vasculitis from anti-GBM disease?
- A. Relapsing course (Correct Answer)
- B. Crescentic glomerulonephritis
- C. Rapid progression
- D. Pulmonary hemorrhage
Explanation: ### Relapsing course - ANCA-associated vasculitis (AAV) often has a **relapsing-remitting course**, meaning patients can experience periods of active disease followed by remission, and then subsequent flares [1]. - In contrast, **anti-glomerular basement membrane (anti-GBM) disease** is typically a monophasic illness without spontaneous relapses once treated. *Crescentic glomerulonephritis* - Both ANCA-associated vasculitis and anti-GBM disease can cause **crescentic glomerulonephritis**, which is a rapid, progressive inflammatory process in the glomeruli [2, 3]. - This feature is characteristic of **rapidly progressive glomerulonephritis (RPGN)** and does not differentiate between the two conditions [2]. *Rapid progression* - Both ANCA-associated vasculitis and anti-GBM disease are known for their **rapid progression** to end-stage renal disease if left untreated [1]. - This similarity highlights their severe nature but does not serve as a distinguishing factor. *Pulmonary hemorrhage* - **Pulmonary hemorrhage (diffuse alveolar hemorrhage)** can occur in both ANCA-associated vasculitis (especially in GPA and MPA) and anti-GBM disease (Goodpasture's syndrome) [2, 3]. - This overlapping manifestation means it cannot be used to differentiate between the two conditions.
Question 5: A 12-year-old boy presents with weak pulses in the upper limbs, a blood pressure of 90/60 mmHg , and retinal hemorrhages. What is the most likely diagnosis?
- A. Henoch-Schönlein purpura (HSP)
- B. Polyarteritis nodosa (PAN)
- C. Takayasu arteritis (Correct Answer)
- D. Microscopic polyangiitis
Explanation: ***Takayasu arteritis*** - **Weak pulses** in the upper limbs, **lower blood pressure** (90/60 mmHg), and **retinal hemorrhages** are classic signs of Takayasu arteritis, which primarily affects the aortic arch and its major branches. [1] - This condition is also known as "pulseless disease" due to the significant narrowing of peripheral arteries, leading to diminished or absent pulses. [1] *Henoch-Schönlein purpura (HSP)* - HSP is characterized by a **palpable purpuric rash**, **arthralgia**, **abdominal pain**, and **renal involvement** (hematuria/proteinuria), none of which are explicitly mentioned here. - It typically affects **small vessels** and does not cause weak pulses in the upper limbs or systemic hypotension in this manner. *Polyarteritis nodosa (PAN)* - PAN is a **necrotizing vasculitis** of medium-sized arteries, often presenting with **fever**, **weight loss**, **myalgia**, and visceral infarcts. - While it can affect various organs, it does not typically cause the specific pattern of weak upper limb pulses and retinal hemorrhages observed here, which points to large vessel involvement. *Microscopic polyangiitis* - This is a **small-vessel vasculitis** characterized by **glomerulonephritis** and **pulmonary capillaritis**, often presenting with hemoptysis and rapidly progressive renal failure. - It does not cause the large vessel symptoms like weak upper limb pulses or significant systemic hypotension seen in the patient.
Question 6: A patient presents with cutaneous vasculitis, glomerulonephritis and peripheral neuropathy. What investigation is to be performed next for work up?
- A. HBsAg
- B. RA factor
- C. CRP
- D. ANCA (Correct Answer)
Explanation: **ANCA** - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points strongly towards a Systemic Vasculitis [1]. **ANCA** (anti-neutrophil cytoplasmic antibodies) are crucial for diagnosing and classifying **ANCA-associated vasculitides**, such as **Granulomatosis with Polyangiitis (GPA)**, **Microscopic Polyangiitis (MPA)**, and **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, which perfectly fit this clinical picture [1]. - Identification of specific ANCA patterns (p-ANCA or c-ANCA) and their corresponding target antigens (e.g., **MPO** or **PR3**) is essential for confirming the diagnosis and guiding treatment. *HBsAg* - While **Hepatitis B virus (HBV) infection** can cause **polyarteritis nodosa (PAN)**, which may present with vasculitis and neuropathy, it typically does not involve **glomerulonephritis** as a primary feature [1]. - Testing for HBsAg would be relevant if PAN was strongly suspected or if other risk factors for HBV were present, but ANCA testing is more direct for the given clinical triad. *RA factor* - **Rheumatoid factor (RF)** is primarily associated with **Rheumatoid Arthritis**, which is an inflammatory joint disease and does not typically present with this triad of **vasculitis**, **glomerulonephritis**, and **neuropathy** [2]. - Although some connective tissue diseases can have vasculitic manifestations, RF itself is not a primary diagnostic marker for systemic vasculitis. *CRP* - **C-reactive protein (CRP)** is a general **marker of inflammation**, which would undoubtedly be elevated in a patient with systemic vasculitis [1]. - However, CRP is **non-specific** and would not help in narrowing down the diagnosis or determining the etiology of the vasculitis, making it less useful for specific workup compared to ANCA.
Question 7: A 30-year-old construction worker had a partial traumatic nail avulsion. 3 weeks later he presents with the presentation shown below. What is the diagnosis?
- A. Pyoderma gangrenosum
- B. Pott's puffy tumor
- C. Pyogenic granuloma (Correct Answer)
- D. Acute paronychia
Explanation: ***Pyogenic granuloma*** - The image shows a **fleshy, red, often ulcerated nodule** following a partial traumatic nail avulsion, which is highly characteristic of a pyogenic granuloma. - These lesions are **reactive vascular proliferations** that typically develop rapidly at sites of trauma or inflammation. *Pyoderma gangrenosum* - Pyoderma gangrenosum characteristically presents as a rapidly enlarging, painful **ulcer with violaceous undermined borders** and often a purulent base, which differs from the described lesion. - It is typically associated with **systemic diseases**, such as inflammatory bowel disease or hematologic malignancies, and does not typically present as a focal, exophytic growth after localized trauma. *Pott's puffy tumor* - Pott's puffy tumor is a subperiosteal abscess of the frontal bone, usually caused by sinusitis, leading to a **forehead swelling** with osteomyelitis and epidural abscess. - This condition involves the **skull** and brain, not the nail bed, and presents with different clinical features like fever, headache, and periorbital edema. *Acute paronychia* - Acute paronychia is an **infection of the nail fold**, presenting with pain, redness, and swelling around the nail, often with pus accumulation. - While it can follow minor trauma, it is characterized by **inflammatory signs of infection** in the paronychial area, not a rapidly growing, exuberant granulation-like tissue as shown.
Question 8: Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?
- A. Hip fracture and prolonged immobilization
- B. Young age (< 25 years) (Correct Answer)
- C. Deficiency of Protein C and Protein S
- D. Factor V Leiden mutation
Explanation: The risk of developing Deep Vein Thrombosis (DVT) is governed by **Virchow’s Triad**: endothelial injury, stasis of blood flow, and hypercoagulability. ### Why "Young age (< 25 years)" is the correct answer: Age is a significant independent risk factor for DVT. The incidence of venous thromboembolism (VTE) is extremely low in children and young adults (approximately 1 in 10,000) and increases exponentially with age. This is due to age-related changes such as decreased vessel wall elasticity, increased plasma levels of clotting factors, and higher rates of comorbidities or immobility. Therefore, being under 25 is considered a **protective factor** rather than a risk factor. ### Explanation of Incorrect Options: * **Hip fracture and prolonged immobilization:** These represent two arms of Virchow’s Triad. Surgery/trauma causes endothelial injury, while immobilization leads to venous stasis. Orthopedic surgeries (hip/knee) carry the highest risk of DVT among all surgical procedures. * **Deficiency of Protein C and Protein S:** These are natural anticoagulants that inhibit Factors Va and VIIIa. Their deficiency leads to a state of **hereditary thrombophilia**, significantly increasing the risk of clot formation. * **Factor V Leiden mutation:** This is the **most common inherited cause** of hypercoagulability. It involves a mutation that makes Factor V resistant to inactivation by activated Protein C (APC resistance). ### NEET-PG High-Yield Pearls: * **Most common inherited risk factor for DVT:** Factor V Leiden mutation. * **Most common acquired risk factor for DVT:** Recent surgery or trauma. * **Gold Standard Investigation for DVT:** Contrast Venography (though Duplex Ultrasound is the initial investigation of choice). * **Trousseau’s Sign:** Migratory thrombophlebitis associated with visceral malignancy (most commonly pancreatic cancer).
Question 9: Allen's test is used to diagnose which condition?
- A. Thoracic outlet syndrome
- B. Palmar arch insufficiency (Correct Answer)
- C. Superior vena cava syndrome
- D. Coarctation of the aorta
Explanation: **Explanation:** **Allen’s Test** is a clinical bedside assessment used to evaluate the **patency of the radial and ulnar arteries** and the adequacy of the **dual blood supply to the hand via the palmar arches**. 1. **Why Option B is Correct:** The test is performed by asking the patient to clench their fist while the clinician compresses both the radial and ulnar arteries at the wrist. When the patient opens their hand (which appears blanched), the clinician releases pressure from one artery (usually the ulnar). If the palm flushes (reperfuses) within 5–15 seconds, the arch is patent. If the hand remains pale, it indicates **palmar arch insufficiency** or ulnar artery occlusion. This is mandatory before procedures like **Radial Artery Harvesting** (for CABG) or **Arterial Blood Gas (ABG)** sampling to ensure the hand remains viable if the radial artery is compromised. 2. **Why Other Options are Incorrect:** * **Thoracic Outlet Syndrome (TOS):** Diagnosed using **Adson’s test**, Roos test, or Wright’s maneuver, which assess compression of the neurovascular bundle at the neck/shoulder. * **Superior Vena Cava (SVC) Syndrome:** Characterized by facial puffiness and dilated neck veins; diagnosed via clinical signs (Pemberton’s sign) and CT imaging. * **Coarctation of the Aorta:** Identified by radio-femoral delay and rib notching on X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen’s Test:** The standard version used today where only one artery is released at a time. * **Normal Refill Time:** Less than 7 seconds is considered normal; 7–15 seconds is equivocal; **>15 seconds is abnormal**. * **Alternative:** If Allen’s test is inconclusive, **Pulse Oximetry** or **Doppler Ultrasound** can be used for more objective assessment.
Question 10: What is the preferred material for femoro-popliteal bypass?
- A. Dacron
- B. Polytetrafluoroethylene (PTFE)
- C. Saphenous vein (Correct Answer)
- D. Gore-Tex
Explanation: **Explanation:** The **Great Saphenous Vein (GSV)** is considered the "gold standard" conduit for infrainguinal arterial bypass, including femoro-popliteal bypass. **Why Saphenous Vein is Correct:** The GSV is preferred due to its superior **long-term patency rates** compared to synthetic grafts. Being an autologous living tissue, it possesses an intact endothelial lining that produces nitric oxide and prostacyclin, which are essential for preventing thrombosis. It also has better resistance to infection and handles mechanical stress (like knee flexion) more effectively than rigid synthetic materials. **Why Other Options are Incorrect:** * **Dacron (Polyester):** While excellent for large-diameter, high-flow vessels like the aorta (e.g., AAA repair), it has poor patency in smaller peripheral vessels due to high thrombogenicity and compliance mismatch. * **PTFE (Polytetrafluoroethylene) & Gore-Tex:** PTFE (Gore-Tex is a brand name) is the second-line choice used only when the saphenous vein is unavailable or inadequate. While acceptable for bypasses ending *above* the knee, its performance is significantly inferior to the GSV for *below-knee* bypasses due to the risk of intimal hyperplasia and thrombosis. **High-Yield Clinical Pearls for NEET-PG:** * **Patency Rule:** Autologous vein > Synthetic graft. * **Reversed vs. In-situ:** The GSV can be used as a "reversed" graft (to bypass valves) or "in-situ" (where valves are lysed with a valvulotome). * **Infection:** In a contaminated field or infected site, synthetic grafts are strictly contraindicated; autologous veins must be used. * **Alternative Veins:** If the GSV is absent, the Small Saphenous Vein or cephalic/basilic veins are the next autologous options.
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