Rheumatology and Immunology Practice Questions

Q: A 42-year-old female presents with palpable purpura on her buttocks, abdominal pain, and arthropathy. What is the most likely diagnosis?

Henoch-Schonlein purpura (HSP). ### Explanation **Correct Answer: B. Henoch-Schönlein Purpura (HSP)** **Why it is correct:** The clinical triad of **palpable purpura** (typically on the buttocks and lower extremities), **abdominal pain** (colic/gastrointestinal bleeding), and **arthropathy** (joint pain) is the classic presentation of Henoch-Schönlein Purpura (HSP), also known as IgA Vasculitis. It is a small-vessel vasculitis characterized by the deposition of **IgA-dominant immune complexes**. While more common in children, it can occur in adults and often follows an upper respiratory tract infection. **Why the other options are incorrect:** * **A. Sweet Syndrome:** This is a "Neutrophilic Dermatosis." It presents with tender, erythematous plaques or nodules and fever, not palpable purpura. Histology shows a dense dermal neutrophilic infiltrate without vasculitis. * **C. Purpura Fulminans:** This is a life-threatening condition associated with Disseminated Intravascular Coagulation (DIC) and protein C/S deficiency. It presents with rapidly progressing large ecchymotic areas and skin necrosis, rather than small palpable purpuric papules. * **D. Meningococcemia:** While it presents with a petechial/purpuric rash, it is an acute medical emergency characterized by high fever, hypotension, and signs of sepsis/meningitis. The distribution is usually generalized rather than localized to the buttocks. **High-Yield NEET-PG Pearls:** * **Most common systemic vasculitis in children.** * **Histopathology:** Shows Leukocytoclastic Vasculitis (LCV) with IgA deposits on Direct Immunofluorescence (DIF). * **Renal Involvement:** The most serious long-term complication is HSP nephritis (identical to IgA nephropathy/Berger’s disease). * **Tetrad of HSP:** Palpable purpura, Arthritis/Arthralgia, Abdominal pain, and Renal disease.

Q: ASLO titres are used in the diagnosis of which of the following conditions?

Acute rheumatic fever. ### Explanation **Correct Answer: B. Acute Rheumatic Fever** **Why it is correct:** Anti-streptolysin O (ASLO) is an antibody directed against **Streptolysin O**, an exotoxin produced by **Group A Beta-hemolytic Streptococci (GABS)**. Acute Rheumatic Fever (ARF) is a non-suppurative sequela of a GABS pharyngeal infection. According to the **Revised Jones Criteria**, evidence of a preceding streptococcal infection is essential for the diagnosis of ARF (except in cases of chorea or indolent carditis) [1]. An elevated or rising ASLO titre is the most commonly used laboratory evidence to confirm this prior infection. **Why the other options are incorrect:** * **A. Acute Rheumatoid Arthritis:** This is an autoimmune chronic inflammatory disorder. Diagnosis relies on clinical features, Rheumatoid Factor (RF), and Anti-CCP antibodies, not streptococcal markers [1]. * **C. Ankylosing Spondylitis:** This is a seronegative spondyloarthropathy strongly associated with the **HLA-B27** gene. It involves the sacroiliac joints and spine; ASLO has no diagnostic role here. * **D. Osteoarthritis:** This is a degenerative joint disease caused by "wear and tear" of articular cartilage. It is not inflammatory or post-infectious, so ASLO titres remain normal. **High-Yield Clinical Pearls for NEET-PG:** * **Peak Timing:** ASLO titres begin to rise 1–3 weeks after infection, peak at 3–5 weeks, and may persist for months. * **Skin Infections:** ASLO titres often do **not** rise significantly following streptococcal pyoderma (impetigo). In such cases, the **Anti-DNase B** test is more reliable. * **Diagnostic Threshold:** A single titre is less significant than a rising titre; however, a value >200 IU/ml in adults or >333 IU/ml in children is generally considered elevated. * **Other Markers:** If ASLO is negative but ARF is strongly suspected, order Anti-DNase B or Anti-hyaluronidase.

Q: Heberden node denotes involvement of which joint?

Distal interphalangeal joint. **Explanation:** **Heberden’s nodes** are a classic clinical hallmark of **Osteoarthritis (OA)**. They represent bony overgrowths (osteophytes) that occur specifically at the **Distal Interphalangeal (DIP) joints** [1]. These nodes are caused by repeated mechanical stress and cartilage degradation, leading to reactive bone formation. They are more common in women and often have a strong genetic predisposition [1]. **Analysis of Options:** * **Option A (Correct):** Heberden’s nodes are pathognomonic for OA involvement of the **DIP joints** [1]. * **Option B (Incorrect):** Bony enlargements at the **Proximal Interphalangeal (PIP) joints** are known as **Bouchard’s nodes** [1]. While also seen in OA, they are distinct from Heberden’s nodes. * **Option C (Incorrect):** The **Metacarpophalangeal (MCP) joints** are typically spared in primary Osteoarthritis. Involvement of the MCP joints is a classic feature of **Rheumatoid Arthritis (RA)**. * **Option D (Incorrect):** The first **Metatarsophalangeal (MTP) joint** is the most common site for **Gout** (Podagra) and can also be affected by OA (Hallux rigidus), but it is not the site of Heberden’s nodes. **High-Yield Clinical Pearls for NEET-PG:** * **DIP involvement:** Think Osteoarthritis or Psoriatic Arthritis. (Note: RA characteristically *spares* the DIP). * **Nodal OA:** The presence of Heberden’s nodes often signifies a specific subset of OA called "Nodal Generalized Osteoarthritis" [1]. * **Radiological findings in OA:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [1]. * **Hand Deformities:** Remember the mnemonic: **H**eberden = **H**igh (Distal); **B**ouchard = **B**elow (Proximal).

Q: What is the last joint typically involved in ankylosing spondylitis?

Temporomandibular joint. **Explanation:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton. The disease follows a characteristic **ascending pattern**, starting from the base of the spine and progressing cranially. **1. Why Temporomandibular Joint (TMJ) is the correct answer:** The TMJ is involved in only about 10% of patients and typically occurs in the very late stages of the disease. Because AS progresses from the sacroiliac joints upward through the lumbar, thoracic, and cervical spine, the TMJ—being the most superiorly located joint involved in the disease process—is usually the last to be affected. **2. Analysis of Incorrect Options:** * **Sacroiliac Joint (A):** This is the **first** joint to be involved. Bilateral, symmetrical sacroiliitis is the hallmark and often the presenting radiographic feature of AS. * **Costovertebral Joint (C):** These are involved as the disease ascends to the thoracic spine. Involvement leads to reduced chest expansion, a key clinical diagnostic criterion. * **Vertebral Apophyseal Facet Joint (D):** These are involved early to mid-course as the disease moves up the spinal column, leading to the characteristic "Bamboo Spine" appearance due to syndesmophyte formation and facet joint fusion. **Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated (>90% of cases). * **Schober’s Test:** Used to assess restricted lumbar flexion. * **Radiology:** Look for "Bamboo spine" (syndesmophytes), "Dagger sign" (ossification of supraspinous/interspinous ligaments), and "Romanus lesions" (shiny corners of vertebrae). * **Extra-articular manifestation:** Acute anterior uveitis is the most common. * **First-line Treatment:** NSAIDs and physical therapy.

Q: Which of the following is NOT true about the condition?

Tender nodes. ***Tender nodes*** - **Rheumatoid nodules** are characteristically **non-tender** firm subcutaneous masses that occur in approximately 20-30% of RA patients. - These nodules are typically found over **pressure points** like elbows and are associated with **positive rheumatoid factor** and more severe disease. *Piano key movement of ulnar styloid* - This is a classic sign of **distal radioulnar joint subluxation** commonly seen in advanced rheumatoid arthritis. - The **ulnar styloid** can be depressed like a piano key due to **synovial destruction** and ligamentous laxity at the wrist. *Z line deformity* - Also known as **Z-thumb deformity**, this involves **hyperextension** at the metacarpophalangeal joint and **flexion** at the interphalangeal joint. - Results from **synovial inflammation** destroying joint capsules and tendons, leading to characteristic hand deformities in RA. *Atlantoaxial deformity* - **Atlantoaxial subluxation** occurs in up to 25% of RA patients due to **synovial proliferation** affecting the C1-C2 joint. - Can lead to **cervical myelopathy** and requires careful monitoring, especially before intubation or surgery.

Question 1

A 42-year-old female presents with palpable purpura on her buttocks, abdominal pain, and arthropathy. What is the most likely diagnosis?

Accepted Answer

Henoch-Schonlein purpura (HSP)

Answer

Sweet syndrome

Answer

Purpura fulminans

Answer

Meningococcemia

Question 2

ASLO titres are used in the diagnosis of which of the following conditions?

Accepted Answer

Acute rheumatic fever

Answer

Acute rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Osteoarthritis

Question 3

In a pregnant woman, all of the following drugs can be given for Systemic Lupus Erythematosus (SLE), EXCEPT:

Accepted Answer

Methotrexate

Answer

Sulfasalazine

Answer

Hydroxychloroquine

Answer

Prednisone

Question 4

A 68-year-old man presents with an acutely red and swollen right great toe with no history of trauma. Which of the following findings is most useful for making a diagnosis of gout in this patient?

Accepted Answer

Good response to colchicine trial

Answer

Persistent elevation of serum uric acid

Answer

Radiograph showing marginal joint erosion in the first metatarsophalangeal (MTP) joint

Answer

An associated right ankle effusion

Question 5

Heberden node denotes involvement of which joint?

Accepted Answer

Distal interphalangeal joint

Answer

Proximal interphalangeal joint

Answer

Metacarpophalangeal joint

Answer

Metatarsophalangeal joint

Question 6

Macrophage activation syndrome is seen in association with which of the following conditions?

Accepted Answer

Systemic lupus erythematosus

Answer

Systemic sclerosis

Answer

Sweet's syndrome

Answer

Polyarteritis nodosa

Question 7

A patient presents with progressive muscle weakness, difficulty rising from a chair, and climbing stairs. Physical examination reveals lilac-colored discoloration of the upper eyelids and periorbital edema. Laboratory tests show elevated creatinine phosphokinase and a positive antinuclear antibody. Which of the following antibodies is most likely to be present in this patient?

Accepted Answer

Anti-Mi2 antibodies

Answer

Anti-Jo1 antibodies

Answer

Anti-P155 antibody

Answer

Anti-P140 antibody

Question 8

What is the last joint typically involved in ankylosing spondylitis?

Accepted Answer

Temporomandibular joint

Answer

Sacroiliac joint

Answer

Costovertebral joint

Answer

Vertebral apophyseal facet joint

Question 9

A 20-year-old woman presents with bilateral conductive deafness, palpable purpura on the legs, and hemoptysis. Radiograph of the chest shows a thin-walled cavity in the left lower zone. Investigations reveal a total leukocyte count of 12,000/mm³, red cell casts in the urine, and serum creatinine of 3 mg/dL. What is the most probable diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Henoch-Schonlein purpura

Answer

Polyarteritis nodosa

Answer

Disseminated tuberculosis

Question 10

Which of the following is NOT true about the condition?

Accepted Answer

Tender nodes

Answer

Piano key movement of ulnar styloid

Answer

Z line deformity

Answer

Atlantoaxial deformity

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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