Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT a feature of Rheumatoid arthritis?

Osteosclerosis of the joint. **Explanation:** Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disease primarily affecting the **synovium**. The hallmark of RA is inflammatory pannus formation, which leads to bone destruction rather than bone formation. **Why Osteosclerosis is NOT a feature:** **Osteosclerosis** (increased bone density/hardening) is a characteristic feature of **Osteoarthritis (OA)**, a degenerative joint disease. In OA, the loss of cartilage leads to increased mechanical stress on the subchondral bone, resulting in sclerosis and osteophyte formation. In contrast, the inflammatory cytokines (like TNF-α and IL-1) in RA activate osteoclasts, leading to bone loss (osteopenia/erosion) rather than hardening. **Analysis of other options:** * **Soft tissue swelling:** This is the earliest radiographic sign of RA, caused by synovial hypertrophy and joint effusion. * **Narrowing of the joint space:** As the inflammatory pannus destroys the articular cartilage, the space between the bone ends decreases symmetrically. * **Periarticular osteoporosis:** This is a classic early sign of RA. Localized inflammation increases blood flow (hyperemia) to the joint, which promotes demineralization of the bone immediately surrounding the inflamed synovium. **NEET-PG High-Yield Pearls:** * **Radiological Hallmarks of RA:** Symmetric joint space narrowing, periarticular osteopenia, marginal erosions (at the "bare area"), and joint deformities (e.g., Swan-neck, Boutonniere). * **Radiological Hallmarks of OA:** Asymmetric joint space narrowing, **subchondral sclerosis**, subchondral cysts (Geodes), and osteophytes. * **Key Distinction:** RA is an **erosive** disease; OA is a **productive** (bone-forming) disease.

Q: What is the treatment of choice (TOC) in psoriatic arthropathy?

Methotrexate. **Explanation:** **Methotrexate (MTX)** is considered the traditional **Treatment of Choice (TOC)** and the first-line Disease-Modifying Anti-Rheumatic Drug (DMARD) for psoriatic arthropathy. It is a folate antagonist that inhibits dihydrofolate reductase, effectively suppressing both the cutaneous hyperproliferation and the systemic inflammation responsible for joint destruction. It is particularly favored because it treats both the skin lesions and the arthritis simultaneously. **Analysis of Incorrect Options:** * **5-Fluorouracil:** This is a pyrimidine analog used primarily as a topical treatment for actinic keratosis or superficial basal cell carcinomas, and systemically for visceral malignancies. It has no role in managing psoriatic arthritis. * **PUVA:** While highly effective for extensive plaque psoriasis (skin), UV radiation cannot penetrate deep enough to treat joint inflammation. Furthermore, PUVA is now largely replaced by Narrowband UVB (NBUVB) due to safety profiles. * **Steroids:** Systemic steroids are generally **avoided** in psoriasis. While they may provide temporary joint relief, their withdrawal often triggers a severe, life-threatening rebound flare of skin symptoms, such as **Pustular Psoriasis**. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard (Modern):** While MTX is the traditional TOC, **TNF-alpha inhibitors** (e.g., Etanercept, Adalimumab) are now considered the most effective for preventing radiological progression of joint damage. * **Radiology:** Look for the "Pencil-in-cup" deformity on X-rays. * **Nail Changes:** Pitting and onycholysis are strong clinical predictors of joint involvement (Distal Interphalangeal joints). * **Drug Side Effect:** Always supplement MTX with **Folic acid** to reduce GI toxicity and bone marrow suppression.

Q: A 29-year-old male with a history of a long leisure trip presented with right knee pain and a swollen joint. What is the most likely diagnosis?

Reiter's disease. ### Explanation **Correct Option: C. Reiter's Disease (Reactive Arthritis)** The clinical presentation of a young male with acute monoarthritis (swollen right knee) following a "long leisure trip" is a classic vignette for **Reactive Arthritis**. In the context of NEET-PG, a "long trip" often implies exposure to new sexual partners (leading to *Chlamydia trachomatis* urethritis) or unsanitary food (leading to enteric infections like *Salmonella* or *Campylobacter*). Reactive Arthritis typically presents as an asymmetric oligoarthritis, predominantly affecting the lower limbs, 1–4 weeks after a urogenital or gastrointestinal infection [1]. **Why other options are incorrect:** * **A. Sarcoidosis:** While it can cause acute arthritis (Lofgren’s syndrome), it usually presents with bilateral hilar lymphadenopathy, erythema nodosum, and symmetric ankle involvement rather than isolated knee pain following travel. * **B. Tuberculosis:** TB arthritis is usually a chronic, slowly progressive monoarthritis (Poncet’s disease is rare). It does not typically follow the acute "post-travel" pattern seen in reactive cases. * **D. Behcet’s Disease:** This is characterized by the triad of oral ulcers, genital ulcers, and uveitis. While it causes arthritis, the lack of mucosal lesions makes it less likely than Reiter's in this scenario. **Clinical Pearls for NEET-PG:** * **The Classic Triad:** "Can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)" [1]. * **HLA Association:** Strongly associated with **HLA-B27** (seen in 60–80% of cases) [2]. * **Cutaneous Markers:** Look for **Keratoderma blennorrhagicum** (brownish plaques on palms/soles) and **Circinate balanitis** [1]. * **Joint Fluid:** Sterile on culture (hence "reactive"), but high inflammatory markers.

Q: A 20-year-old woman presents with diplopia, syncopal episodes, and paresthesias in both hands (left hand tingling, right hand numbness). Physical examination reveals absent pulses in the right arm. Laboratory findings include an elevated erythrocyte sedimentation rate and thrombocytosis. Angiography demonstrates narrowing and occlusion of multiple arteries, including the right subclavian artery. The patient later develops heart failure and dies from massive pulmonary edema. Autopsy reveals a thickened aorta with vasculitis and fragmentation of elastic fibers. What is the most likely diagnosis?

Takayasu arteritis. **Explanation:** The clinical presentation is classic for **Takayasu Arteritis (TA)**, also known as "Pulseless Disease." **Why Takayasu Arteritis is correct:** TA is a chronic, large-vessel granulomatous vasculitis that primarily affects the **aorta and its main branches** [1]. * **Demographics:** It typically affects young women (<40 years). * **Clinical Features:** The "pulseless" nature (absent right arm pulse), limb claudication/paresthesias, and neurological symptoms (diplopia, syncope due to carotid involvement) are hallmark signs. * **Pathology:** Autopsy findings of a thickened aorta with elastic fiber fragmentation and transmural inflammation are pathognomonic. * **Laboratory:** Elevated ESR and thrombocytosis indicate an active inflammatory state [1]. **Why the other options are incorrect:** * **Buerger Disease (Thromboangiitis obliterans):** Affects small/medium vessels in young male smokers; involves distal extremities (gangrene) rather than the aorta. * **Churg-Strauss (EGPA):** A small-vessel vasculitis characterized by asthma, eosinophilia, and p-ANCA positivity [3]. Biopsy revealed a small-vessel vasculitis with eosinophilic infiltration [3]. * **Kawasaki Disease:** Primarily affects children; involves medium-sized vessels, most notably the coronary arteries, leading to aneurysms [2]. **NEET-PG High-Yield Pearls:** * **Classification:** Large vessel vasculitis (along with Giant Cell Arteritis) [1]. * **Gold Standard Diagnosis:** CT/MR Angiography (shows "string of pearls" appearance or smooth tapering/stenosis). * **Complications:** Aortic regurgitation and renovascular hypertension (due to renal artery stenosis) are common. * **Treatment:** Glucocorticoids are the first-line therapy.

Q: A young female presented with headache and malaise. Her blood pressure is high and differs by more than 10mm Hg between both upper limbs. The patient is diagnosed with pulseless disease. Which of the following blood vessels is commonly affected in this type of vasculitis?

Renal artery. **Explanation:** The clinical presentation of a young female with headache, hypertension, and a significant blood pressure difference between limbs points toward **Takayasu Arteritis (TA)**, also known as "Pulseless Disease." This is a chronic, large-vessel vasculitis that primarily involves the aorta and its major branches [1]. **1. Why Renal Artery is correct:** In Takayasu Arteritis, the **renal artery** is the most commonly involved branch of the abdominal aorta (occurring in up to 30-60% of cases). Renal artery stenosis leads to activation of the Renin-Angiotensin-Aldosterone System (RAAS), resulting in **renovascular hypertension**, which explains the patient's high blood pressure [2]. **2. Why other options are incorrect:** * **Coeliac axis:** While the coeliac and superior mesenteric arteries can be involved, they are less frequently affected than the renal arteries. * **Coronaries:** Coronary artery involvement (ostial stenosis) occurs in less than 10% of cases and is not a primary diagnostic feature. * **Radial artery:** TA affects large vessels (aorta and its primary branches). The radial artery is a medium-to-small vessel; while the radial *pulse* may be absent due to proximal subclavian or axillary artery stenosis, the radial artery itself is not the primary site of pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females <40 years (Asian descent). * **Vessel Involvement:** The **Subclavian artery** is the most common vessel involved overall (causing the BP discrepancy), but the **Renal artery** is the most common cause of secondary hypertension in these patients. * **Diagnosis:** Gold standard is **Digital Subtraction Angiography (DSA)** or MR Angiography showing "string of pearls" or skip lesions [2]. * **Classification:** It is a **Large Vessel Vasculitis** (along with Giant Cell Arteritis) [1]. * **Treatment:** Glucocorticoids are the first-line therapy.

Q: Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?

Osteoarthritis. The correct answer is **Osteoarthritis (OA)**. This question tests your ability to differentiate joint involvement patterns in common arthritides, a high-yield topic for NEET-PG. **Why Osteoarthritis is correct:** Osteoarthritis typically affects weight-bearing joints and specific joints of the hand. The classic triad of hand involvement in OA includes: 1. **Distal Interphalangeal (DIP) joints:** Presence of Heberden’s nodes [1]. 2. **Proximal Interphalangeal (PIP) joints:** Presence of Bouchard’s nodes [1]. 3. **1st Carpometacarpal (CMC) joint:** Leads to "squaring" of the hand [3]. A hallmark of nodal OA is the **sparing of the wrist** (except for the 1st CMC) and the MCP joints [1]. **Why other options are incorrect:** * **Rheumatoid Arthritis (RA):** RA characteristically involves the MCP and PIP joints but **spares the DIP joints** [3]. Furthermore, wrist involvement is almost universal in RA, unlike the sparing seen in this case. * **Pseudogout (CPPD):** While it can mimic OA, it typically involves the **radiocarpal (wrist) joint** and the MCP joints (especially 2nd and 3rd) [2], often with associated chondrocalcinosis. * **Psoriatic Arthropathy:** While it frequently involves the DIP joints, it is usually associated with dactylitis ("sausage digit"), skin/nail changes, and often involves the wrist in a polyarticular pattern. **NEET-PG Clinical Pearls:** * **DIP Involvement:** Think OA, Psoriatic Arthritis, or Multicentric Reticulohistiocytosis [1]. * **DIP Sparing:** Think Rheumatoid Arthritis [3]. * **1st CMC Joint:** The most common site of OA in the thumb; causes pain during pinch or grip activities [3]. * **Radiology of OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [2].

Q: Which is the best marker of Systemic Lupus Erythematosus (SLE)?

Anti-dsDNA antibodies. The diagnosis and monitoring of Systemic Lupus Erythematosus (SLE) rely on specific serological markers. While **ANA (Antinuclear Antibody)** is the best *screening* test due to its high sensitivity (95-99%) [1], **Anti-dsDNA** is considered the best marker for overall management [2]. **1. Why Anti-dsDNA is the correct answer:** * **High Specificity:** It is highly specific for SLE (>95%). * **Disease Activity:** Unlike other antibodies, its titers fluctuate with disease activity [2]. It is the best marker for monitoring **flares**. * **Organ Involvement:** High titers are strongly associated with **Lupus Nephritis** [1]. **2. Analysis of Incorrect Options:** * **Anti-Sm (Smith) antibodies:** These are the **most specific** markers for SLE [1]. However, they are only present in 20-30% of patients and their levels do not correlate with disease activity, making them less useful for ongoing monitoring than Anti-dsDNA. * **Anti-histone antibodies:** These are the hallmark of **Drug-Induced Lupus** (e.g., caused by Hydralazine, Procainamide, or Isoniazid). * **Anti-Ro (SS-A) antibodies:** These are associated with **Neonatal Lupus** (congenital heart block) and **Sjögren’s syndrome** [1]. **Clinical Pearls for NEET-PG:** * **Best Screening Test:** ANA (High sensitivity, low specificity) [1]. * **Most Specific Test:** Anti-Sm. * **Marker for Monitoring/Nephritis:** Anti-dsDNA [2]. * **Drug-Induced Lupus:** Anti-histone (Note: Anti-dsDNA is usually negative here). * **Complement Levels:** During an active SLE flare (especially renal), **C3 and C4 levels decrease** [2].

Question 1

Which of the following is NOT a feature of Rheumatoid arthritis?

Accepted Answer

Osteosclerosis of the joint

Answer

Soft tissue swelling

Answer

Narrowing of the joint space

Answer

Periarticular osteoporosis

Question 2

What is the treatment of choice (TOC) in psoriatic arthropathy?

Accepted Answer

Methotrexate

Answer

5-Fluorouracil

Answer

PUVA (Psoralen plus Ultraviolet A)

Answer

Steroids

Question 3

A 29-year-old male with a history of a long leisure trip presented with right knee pain and a swollen joint. What is the most likely diagnosis?

Accepted Answer

Reiter's disease

Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Bechet's disease

Question 4

Multiple small aneurysms are seen on aortography in which condition?

Accepted Answer

Takayasu's arteritis

Answer

Behcet's syndrome

Answer

Polyarteritis nodosa (PAN)

Answer

Wegener's granulomatosis

Question 5

A 29-year-old woman presents with painful swelling of both hands and significant morning stiffness. Physical examination reveals involvement of the proximal interphalangeal and metacarpophalangeal joints. Her rheumatoid factor is positive and antinuclear antibody is negative. Which of the following medications is most likely to improve her joint pain symptoms?

Accepted Answer

NSAID or aspirin

Answer

D-penicillamine

Answer

an antimalarial

Answer

methotrexate

Question 6

A 20-year-old woman presents with diplopia, syncopal episodes, and paresthesias in both hands (left hand tingling, right hand numbness). Physical examination reveals absent pulses in the right arm. Laboratory findings include an elevated erythrocyte sedimentation rate and thrombocytosis. Angiography demonstrates narrowing and occlusion of multiple arteries, including the right subclavian artery. The patient later develops heart failure and dies from massive pulmonary edema. Autopsy reveals a thickened aorta with vasculitis and fragmentation of elastic fibers. What is the most likely diagnosis?

Accepted Answer

Takayasu arteritis

Answer

Buerger disease

Answer

Churg-Strauss disease

Answer

Kawasaki disease

Question 7

A young female presented with headache and malaise. Her blood pressure is high and differs by more than 10mm Hg between both upper limbs. The patient is diagnosed with pulseless disease. Which of the following blood vessels is commonly affected in this type of vasculitis?

Accepted Answer

Renal artery

Answer

Coeliac axis

Answer

Coronaries

Answer

Radial artery

Question 8

Proximal interphalangeal, distal interphalangeal, and 1st carpometacarpal joint involvement with sparing of the wrist is a feature of which condition?

Accepted Answer

Osteoarthritis

Answer

Rheumatoid arthritis

Answer

Pseudogout

Answer

Psoriatic arthropathy

Question 9

Which is the best marker of Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Anti-dsDNA antibodies

Answer

Anti-Sm antibodies

Answer

Anti-histone antibodies

Answer

Anti-Ro antibodies

Question 10

A 25-year-old woman develops painful swelling of both hands and wrists with morning stiffness. Physical examination reveals erythema, swelling, and joint line tenderness of the proximal interphalangeal, metacarpophalangeal, and wrist joints. Her RF is positive, ANA is negative, and x-rays of the hands show early erosive joint changes. Which of the following medications is most likely to prevent progression of disease?

Accepted Answer

Methotrexate

Answer

D-penicillamine

Answer

Antimalarial

Answer

NSAID or aspirin

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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