Rheumatology and Immunology Practice Questions

Q: Which of the following is seen more commonly in rheumatoid arthritis than in ankylosing spondylitis?

Autoantibody against IgG. ### Explanation The correct answer is **D. Autoantibody against IgG**. **1. Why the Correct Answer is Right:** The "Autoantibody against IgG" refers to **Rheumatoid Factor (RF)**, which is an IgM antibody directed against the Fc portion of IgG. Rheumatoid Arthritis (RA) is characterized by the presence of RF and Anti-CCP antibodies. In contrast, Ankylosing Spondylitis (AS) belongs to the group of **Seronegative Spondyloarthropathies**, meaning these patients typically lack RF and other autoantibodies. **2. Why the Other Options are Wrong:** * **A. HLA-B27 haplotype:** This is strongly associated with **Ankylosing Spondylitis** (>90% of cases). While RA is associated with HLA-DR4, HLA-B27 is not a feature of RA. * **B. Sacroiliitis:** This is the hallmark radiographic finding of **Ankylosing Spondylitis** and is essential for its diagnosis. RA typically spares the sacroiliac joints, primarily affecting the small joints of the hands and the cervical spine. * **C. Increased incidence in men:** Ankylosing Spondylitis is significantly more common in **males** (approx. 3:1 ratio). Conversely, Rheumatoid Arthritis is more common in **females** (approx. 3:1 ratio). **3. Clinical Pearls for NEET-PG:** * **Spine Involvement:** In RA, the only part of the spine typically involved is the **Cervical Spine** (specifically Atlanto-axial subluxation). AS involves the entire spine, leading to the classic "Bamboo Spine" appearance. * **Joint Distribution:** RA is a symmetrical peripheral polyarthritis (sparing DIP joints). AS is characterized by axial skeleton involvement and enthesitis (inflammation at the site of tendon/ligament insertion). * **Seronegative Group:** Remember the mnemonic **PEAR** for Seronegative Spondyloarthropathies: **P**soriatic arthritis, **E**nteropathic arthritis, **A**nkylosing spondylitis, and **R**eactive arthritis. All are HLA-B27 associated and RF negative.

Q: A 23-year-old man presents with new low back pain, stiffness, and left eye discomfort. He notes increased sensitivity to sunlight. The back pain is worse at night, described as a dull ache in the back and buttock area. Physical examination reveals paravertebral muscle, iliac crest, and ischial tuberosity tenderness with limited lumbar spine flexion. His eye is inflamed with a constricted pupil. Pelvic x-rays show sacroiliitis. What is the most likely diagnosis for his eye symptoms, considering it is the most common extra-articular manifestation of this condition?

Acute anterior uveitis. The clinical presentation describes a classic case of **Ankylosing Spondylitis (AS)**, a seronegative spondyloarthropathy [1]. The patient exhibits inflammatory back pain (worse at night/rest, stiffness), enthesitis (tenderness at iliac crest/ischial tuberosity), and radiographic sacroiliitis [2]. ### 1. Why Acute Anterior Uveitis is Correct **Acute Anterior Uveitis (AAU)**, also known as iridocyclitis, is the **most common extra-articular manifestation** of Ankylosing Spondylitis, occurring in 25–40% of patients [1]. It typically presents as sudden-onset unilateral eye pain, redness, photophobia (sensitivity to light), and blurred vision. The finding of a **constricted pupil** (due to ciliary spasm) is a hallmark sign that differentiates it from other causes of red eye. ### 2. Why Incorrect Options are Wrong * **Glaucoma:** While secondary glaucoma can be a *complication* of chronic uveitis, it is not the primary manifestation. Acute angle-closure glaucoma presents with a mid-dilated pupil, not a constricted one. * **Keratitis:** This involves corneal inflammation. While it causes photophobia, it is not specifically associated with AS and usually presents with corneal opacities or ulcers. * **Conjunctivitis:** This is a common cause of red eye but is typically painless, lacks photophobia, and does not affect the pupil size or cause deep-seated ache. ### 3. NEET-PG High-Yield Pearls * **HLA-B27:** Strongly associated with AS (>90% of cases) [1]. * **Schober’s Test:** Used to quantify limited lumbar spine flexion. * **Bamboo Spine:** A late radiographic feature due to syndesmophyte formation [2]. * **Treatment of AAU:** Urgent referral to ophthalmology; managed with topical corticosteroids and cycloplegic agents to prevent synechiae. * **Other Extra-articular features:** Aortitis (Aortic regurgitation), Apical lung fibrosis, and IgA nephropathy.

Q: A 27-year-old male presents with low backache that occurs early in the morning, is associated with stiffness, and persists for more than 30 minutes. On examination, his chest expansion is also restricted. What is the most probable diagnosis?

Ankylosing spondylitis. ### Explanation **Correct Answer: D. Ankylosing Spondylitis** **Concept:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton (sacroiliac joints and spine). The hallmark clinical presentation includes **inflammatory back pain**, characterized by: * Onset in young males ( 30 minutes. * Improvement with activity/exercise and worsening with rest. * **Reduced chest expansion** (due to involvement of costovertebral and costotransverse joints), which is a specific diagnostic criterion in the Modified New York Criteria. **Why other options are incorrect:** * **A. Rheumatoid Arthritis:** Typically affects small joints of the hands and feet symmetrically. While it causes morning stiffness, it rarely involves the sacroiliac joints or restricts chest expansion. * **B. Osteoarthritis:** This is a degenerative condition. Pain typically **worsens with activity** and improves with rest. Morning stiffness is brief (usually 90% of cases). * **Radiology:** Look for **"Bamboo Spine"** (due to marginal syndesmophytes) and "Dagger Sign" on X-ray. The earliest radiographic change is **Sacroiliitis**. * **Schober’s Test:** Used to clinically assess restricted lumbar flexion. * **Extra-articular manifestation:** The most common is **Acute Anterior Uveitis**. * **Treatment:** NSAIDs are the first-line treatment; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Q: Which joint is NOT involved in Rheumatoid arthritis according to the 1987 ACR Classification Criteria?

Tarsometatarsal. **Explanation:** Rheumatoid Arthritis (RA) is a chronic inflammatory polyarthritis that characteristically involves **synovial joints**. The 1987 ACR (American College of Rheumatology) criteria emphasize the involvement of specific joint groups, typically sparing certain joints of the hands and feet. **Why Tarsometatarsal (TMT) is the correct answer:** The 1987 ACR criteria specifically exclude certain joints from the definition of "joint swelling/involvement" required for diagnosis. RA typically involves the small joints of the hands (MCP, PIP) and feet (MTP). The **Tarsometatarsal (TMT) joints**, along with the Distal Interphalangeal (DIP) joints and the 1st Carpometacarpal (CMC) joint, are characteristically **spared** in RA. These joints are more commonly involved in Osteoarthritis or Psoriatic Arthritis. **Analysis of Incorrect Options:** * **Knee (A) & Ankle (B):** These are large synovial joints frequently involved in the polyarticular distribution of RA. * **Metatarsophalangeal (D):** MTP joint involvement is a hallmark of RA and is often one of the earliest sites of clinical or radiographic changes (e.g., "daylight sign"). **High-Yield Clinical Pearls for NEET-PG:** * **Spine Involvement:** In the spine, RA **only** involves the **Cervical Spine** (specifically the Atlanto-axial joint). It spares the Thoracic and Lumbar spine because they lack synovial joints (they are symphyses). * **Joints Spared in RA:** DIP joints, 1st CMC joint, TMT joints, and the Thoracolumbar spine. * **Most Common Initial Site:** Small joints of hands and feet (PIP, MCP, MTP). * **2010 ACR/EULAR Criteria:** While the 1987 criteria focused on "rheumatoid nodules" and "radiographic erosions," the 2010 criteria focus on early diagnosis, emphasizing the number and size of joints involved and serology (RF/Anti-CCP).

Q: A 40-year-old female presents with a history of fever, weight loss, polyarthralgia, morning stiffness, and bilateral hand pain. Based on the provided radiological findings, what is the most likely diagnosis?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - Combination of **systemic symptoms** (fever, weight loss), **morning stiffness**, and **bilateral hand pain** with **polyarthralgia** is classic for RA. - Radiological findings typically show **periarticular osteopenia**, **symmetric joint space narrowing** at **MCP/PIP joints**, and **marginal erosions**. *Osteoarthritis* - Primarily affects **weight-bearing joints** and **DIP joints** with **osteophyte formation** and **joint space narrowing**. - Lacks **systemic symptoms** like fever and weight loss, and morning stiffness is typically brief (<30 minutes). *Gout* - Presents with acute **monoarticular attacks**, commonly affecting the **first MTP joint** (podagra). - Radiological findings show **punched-out erosions** with **overhanging edges** and possible **tophi**, not bilateral hand involvement. *Psoriatic arthritis* - Characterized by **asymmetric joint involvement**, often affecting **DIP joints** with **pencil-in-cup deformity**. - Associated with **psoriatic skin lesions** and **nail changes**, which are not mentioned in this case.

Q: What is the most specific symptom of temporal arteritis?

Jaw claudication. **Explanation:** **Temporal Arteritis (Giant Cell Arteritis)** is a large-vessel vasculitis that primarily affects the branches of the external carotid artery. **Why Jaw Claudication is the correct answer:** While headache is the most common symptom, **jaw claudication** (pain in the jaw muscles during chewing that resolves with rest) is the **most specific symptom** (specificity >90%). It occurs due to ischemia of the masseter and temporalis muscles resulting from vasculitis of the maxillary artery and its branches. Its presence significantly increases the likelihood of the diagnosis. **Analysis of Incorrect Options:** * **A. Visual Loss:** This is the most dreaded complication (due to anterior ischemic optic neuropathy), but it is not the most specific. It occurs in about 15-20% of untreated patients [1]. * **C. Temporal Headache:** This is the **most common** presenting symptom (occurring in ~75% of cases) [1]. However, because headaches are ubiquitous in clinical practice, it lacks the specificity of jaw claudication [2]. * **D. Polymyalgia Rheumatica (PMR):** PMR (proximal muscle pain and stiffness) is associated with Temporal Arteritis in about 40-50% of cases [1], but it is a distinct clinical syndrome rather than a specific symptom of the arteritis itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Temporal artery biopsy (look for "skip lesions") [1]. * **Best Initial Test:** ESR (usually >50 mm/hr, often >100 mm/hr) and CRP [1]. * **Treatment:** Immediate high-dose corticosteroids (Prednisone) to prevent permanent blindness [1]. Do not wait for biopsy results to start treatment. * **Demographics:** Almost exclusively occurs in patients >50 years of age.

Question 1

Which of the following is seen more commonly in rheumatoid arthritis than in ankylosing spondylitis?

Accepted Answer

Autoantibody against IgG

Answer

An HLA-B27 haplotype

Answer

Sacroiliitis

Answer

Increased incidence in men

Question 2

Bridge therapy is employed in which of the following conditions?

Accepted Answer

Rheumatoid arthritis

Answer

Mononeuritis multiplex

Answer

Osteoarthritis

Answer

Caplan syndrome

Question 3

A 27-year-old male presents with burning micturition and urethral discharge. After 4 weeks, he develops joint pains involving both knees and ankles, redness of the eyes, and skin lesions. What is the most probable clinical diagnosis?

Accepted Answer

Reiter's syndrome

Answer

Psoriasis vulgaris

Answer

Behcet's syndrome

Answer

Sarcoidosis

Question 4

Which of the following statements is not true about Gout?

Accepted Answer

Aspiration shows urate crystals which are needle-shaped and positively birefringent.

Answer

Alcohol is a risk factor for the disease.

Answer

Tophi are characteristic of gout.

Answer

The great toe is most commonly affected.

Question 5

A 23-year-old man presents with new low back pain, stiffness, and left eye discomfort. He notes increased sensitivity to sunlight. The back pain is worse at night, described as a dull ache in the back and buttock area. Physical examination reveals paravertebral muscle, iliac crest, and ischial tuberosity tenderness with limited lumbar spine flexion. His eye is inflamed with a constricted pupil. Pelvic x-rays show sacroiliitis. What is the most likely diagnosis for his eye symptoms, considering it is the most common extra-articular manifestation of this condition?

Accepted Answer

Acute anterior uveitis

Answer

Glaucoma

Answer

Keratitis

Answer

Conjunctivitis

Question 6

A 27-year-old male presents with low backache that occurs early in the morning, is associated with stiffness, and persists for more than 30 minutes. On examination, his chest expansion is also restricted. What is the most probable diagnosis?

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Gouty arthritis

Question 7

Which of the following statements is false regarding Rheumatoid Arthritis?

Accepted Answer

Ligament fibrosis is common early in the disease

Answer

Often associated with hypertrophy of the synovial membrane

Answer

Rheumatoid nodules are typically painless

Answer

The disorder can cause permanent deformity

Question 8

Which joint is NOT involved in Rheumatoid arthritis according to the 1987 ACR Classification Criteria?

Accepted Answer

Tarsometatarsal

Answer

Knee

Answer

Ankle

Answer

Metatarsophalangeal

Question 9

A 40-year-old female presents with a history of fever, weight loss, polyarthralgia, morning stiffness, and bilateral hand pain. Based on the provided radiological findings, what is the most likely diagnosis?

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Gout

Answer

Psoriatic arthritis

Question 10

What is the most specific symptom of temporal arteritis?

Accepted Answer

Jaw claudication

Answer

Visual loss

Answer

Temporal headache

Answer

Polymyalgia rheumatica

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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