Rheumatology and Immunology Practice Questions

Q: What is the treatment for the lesions seen in Behcet syndrome?

Thalidomide. Behcet syndrome is a multisystemic, chronic relapsing vasculitis characterized by the triad of oral ulcers, genital ulcers, and uveitis. The management of Behcet syndrome is tailored to the specific organ involvement. **Why Thalidomide is the correct answer:** Thalidomide is highly effective for treating **refractory mucocutaneous lesions** (severe oral and genital ulcers) in Behcet syndrome. It acts as a potent TNF-alpha inhibitor and modulates the immune response. While not first-line due to its teratogenic potential and risk of peripheral neuropathy, it is a classic "textbook" answer for resistant cutaneous manifestations in Behcet’s. **Analysis of Incorrect Options:** * **A. Prednisolone:** While systemic corticosteroids are used for acute flares or major organ involvement (like posterior uveitis or CNS disease), they are generally avoided for long-term management of isolated skin/mucosal lesions due to side effects and lack of sustained remission. * **B. Infliximab:** This TNF-alpha inhibitor is reserved for severe, sight-threatening uveitis or refractory gastrointestinal/neurological Behcet’s. It is not the primary choice for standard mucocutaneous lesions. * **D. Rituximab:** This anti-CD20 monoclonal antibody is not a standard treatment for Behcet syndrome, as the pathogenesis is primarily mediated by T-cells and neutrophils rather than B-cells. **NEET-PG High-Yield Pearls:** * **Pathergy Test:** A unique diagnostic feature where a sterile papule/pustule forms 24–48 hours after a skin prick. * **HLA Association:** Strongly associated with **HLA-B51**. * **First-line for Mucocutaneous:** Colchicine is typically the first-line agent for preventing the recurrence of ulcers. * **Vascular Involvement:** Behcet’s is unique among vasculitides as it involves both **arteries and veins** (causing "Pulmonary Artery Aneurysms" and "Venous Thrombosis").

Q: Multiple cavitary lesions in the lungs, hematuria, and renal insufficiency are features in a patient with:

Wegener's granulomatosis. **Explanation:** The clinical triad of **upper/lower respiratory tract involvement** and **glomerulonephritis** is the hallmark of **Wegener’s Granulomatosis** (now known as Granulomatosis with Polyangiitis or GPA) [1]. 1. **Why Wegener’s is correct:** GPA is a small-vessel vasculitis characterized by granulomatous inflammation [2]. Lung involvement typically manifests as **multiple nodules** that frequently undergo **cavitation** (seen in 50% of cases) [1]. Renal involvement presents as Pauci-immune Crescentic Glomerulonephritis, leading to **hematuria** and progressive **renal insufficiency** [2]. It is strongly associated with **c-ANCA (anti-PR3) positivity**. 2. **Why the other options are incorrect:** * **Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis that characteristically **spares the lungs** [1]. While it causes renal artery microaneurysms (leading to hypertension/infarcts), it does not typically cause glomerulonephritis or cavitary lung lesions. * **Churg-Strauss Syndrome (EGPA):** While it involves the lungs and kidneys, its hallmark is **peripheral eosinophilia and severe asthma** [1]. Lung lesions are usually transient opacities (Loeffler-like) rather than multiple cavitary nodules. It is associated with **p-ANCA**. * **Temporal Arteritis:** A large-vessel vasculitis that primarily affects the extracranial branches of the carotid artery [3]. It presents with headaches, jaw claudication, and visual loss, not cavitary lung disease or hematuria. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of GPA:** Sinusitis (saddle nose deformity), Cavitary lung nodules, and Glomerulonephritis [1]. * **Serology:** c-ANCA (Proteinase-3) is highly specific for GPA. * **Biopsy:** Shows necrotizing granulomatous vasculitis [1]. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab) [2].

Q: Extreme widening of the periodontal ligament space on dental radiograph is the characteristic feature of which condition?

Scleroderma. ***Scleroderma*** - **Extreme widening of the periodontal ligament space** is a pathognomonic radiographic finding in scleroderma (systemic sclerosis), caused by **collagen deposition** and **vascular changes** affecting the periodontal structures. - This finding is seen in up to **33% of scleroderma patients** and may be one of the earliest manifestations, often preceding other systemic symptoms. *Paget's disease* - Characterized by **cotton wool appearance** and **loss of lamina dura** on dental radiographs, not uniform periodontal ligament widening. - Shows **hypercementosis** and **root resorption** rather than the characteristic uniform thickening seen in scleroderma. *Pemphigus* - Primarily affects **oral mucosa** with **intraepithelial blistering** and **acantholysis**, without affecting periodontal ligament space. - Radiographic changes are minimal and related to **secondary infection** or **bone loss** from oral ulcerations, not periodontal ligament widening. *All of the above* - Incorrect as only **scleroderma** demonstrates the characteristic extreme periodontal ligament widening pattern. - The other conditions have distinct radiographic features that do not include uniform periodontal ligament space thickening.

Q: A 72-year-old man injures his right knee, which is now swollen and extremely painful to bend. X-rays of the knee rule out a fracture, and joint fluid aspiration reveals an opaque-colored fluid containing rhomboid crystals with weak-positive birefringence. Which of the following is the most appropriate next step in management?

Oral NSAIDs. **Explanation:** **1. Why Oral NSAIDs are correct:** The clinical presentation—an elderly patient with acute monoarthritis and synovial fluid showing **rhomboid-shaped, weakly positive birefringent crystals**—is diagnostic of **Pseudogout** (Calcium Pyrophosphate Deposition Disease or CPPD) [1]. For an acute attack of pseudogout involving one or two joints, the first-line treatment is **Oral NSAIDs** (e.g., Naproxen or Ibuprofen) [1]. These agents effectively reduce the intense inflammation triggered by the crystals. In patients where NSAIDs are contraindicated (e.g., renal failure or peptic ulcer disease), intra-articular corticosteroid injections are preferred. **2. Why the other options are incorrect:** * **Oral Prednisone:** While steroids are used for pseudogout, systemic (oral) steroids are generally reserved for polyarticular involvement or when NSAIDs/Colchicine are contraindicated. Intra-articular injection is preferred over oral for a single joint. * **Intravenous Antibiotics:** This would be the treatment for Septic Arthritis. While septic arthritis is a surgical emergency, the presence of rhomboid crystals confirms a crystalline etiology rather than an infectious one. * **Acetaminophen:** This provides mild analgesia but lacks the potent anti-inflammatory properties required to resolve an acute crystal-induced inflammatory flare. **3. NEET-PG High-Yield Pearls:** * **Crystal Morphology:** * **Pseudogout (CPPD):** Rhomboid/Square, Weakly Positive Birefringence (Blue when parallel to the compensator). * **Gout (MSU):** Needle-shaped, Strongly Negative Birefringence (Yellow when parallel). * **Radiology:** Look for **Chondrocalcinosis** (linear calcification of articular cartilage) on X-rays. * **Common Triggers:** Acute illness, trauma [1], or hyperparathyroidism/hypomagnesemia. * **Most Common Site:** The **Knee** is the #1 site for Pseudogout [1] (unlike the 1st MTP joint in Gout).

Q: What is the most likely diagnosis of this case?

Gout. ***Gout*** - Classic **punched-out erosions** with **overhanging edges** on imaging are pathognomonic for gout, particularly when involving the **first metatarsophalangeal joint**. - Presence of **tophi** (urate crystal deposits) and predilection for the **great toe** are characteristic radiological and clinical features of chronic gout. *Osteomyelitis* - Would show **bone destruction** with **sequestrum formation** and surrounding **soft tissue swelling** on imaging. - Typically associated with **systemic signs** like fever and elevated inflammatory markers, unlike the localized joint changes seen in gout. *Vasculitis* - Primarily affects **blood vessels** causing ischemic changes rather than the specific **joint erosions** seen in this case. - Would present with **systemic symptoms** like skin lesions, organ involvement, and elevated inflammatory markers rather than localized joint pathology. *Rheumatoid Arthritis* - Shows **symmetric polyarticular** involvement with **marginal erosions** and **joint space narrowing**. - Lacks the characteristic **punched-out lesions with overhanging edges** and typically spares the **distal interphalangeal joints** unlike gout's predilection for the first MTP joint.

Question 1

A 17-year-old boy presents with chronic low back pain and stiffness for the past 8 months. He denies any gastrointestinal or genital infections. His temperature is 98.6 F. Laboratory investigations show normal ESR and negative RA factor. X-ray films of the vertebral column show flattening of the lumbar curve and subchondral bone erosion involving the sacroiliac joints. What is the most likely diagnosis?

Accepted Answer

Ankylosing spondylitis

Answer

Degenerative joint disease

Answer

Reiter syndrome

Answer

Seronegative rheumatoid arthritis

Question 2

A patient with rheumatoid arthritis presents with progressive quadriplegia and weakness. The patient has a positive Babinski sign, increased muscle tone in the limbs with exaggerated tendon jerks, and worsening gait. There is no sensory or sphincter involvement. What is the best initial investigation?

Accepted Answer

X-ray of the cervical spine in flexion and extension

Answer

MRI of the brain

Answer

EMG and NCV within 48 hours

Answer

Carotid angiography

Question 3

Which is the best treatment for an over-producer in chronic gout with kidney impairment?

Accepted Answer

Febuxostat

Answer

Allopurinol

Answer

Uricase

Answer

Benzbromarone

Question 4

A 35-year-old man presents with loss of appetite, nausea, vomiting, and fatigue. Laboratory examination confirms the diagnosis of hepatitis B, and the man becomes icteric 2 weeks later. This patient is particularly vulnerable to the development of which of the following disorders?

Accepted Answer

Polyarteritis nodosa

Answer

Berry aneurysm

Answer

Coronary artery aneurysm

Answer

Dissecting aneurysm

Question 5

Which of the following urine findings are characteristic of Systemic Lupus Erythematosus (SLE)?

Accepted Answer

Proteinuria and RBCs

Answer

Proteinuria and RBC casts

Answer

RBC casts

Answer

LE cells

Question 6

What is the treatment for the lesions seen in Behcet syndrome?

Accepted Answer

Thalidomide

Answer

Prednisolone

Answer

Infliximab

Answer

Rituximab

Question 7

Multiple cavitary lesions in the lungs, hematuria, and renal insufficiency are features in a patient with:

Accepted Answer

Wegener's granulomatosis

Answer

Polyarteritis nodosa

Answer

Churg-Strauss syndrome

Answer

Temporal arteritis

Question 8

Extreme widening of the periodontal ligament space on dental radiograph is the characteristic feature of which condition?

Accepted Answer

Scleroderma

Answer

Paget's disease

Answer

Pemphigus

Answer

All of the above

Question 9

A 72-year-old man injures his right knee, which is now swollen and extremely painful to bend. X-rays of the knee rule out a fracture, and joint fluid aspiration reveals an opaque-colored fluid containing rhomboid crystals with weak-positive birefringence. Which of the following is the most appropriate next step in management?

Accepted Answer

Oral NSAIDs

Answer

Oral prednisone

Answer

Intravenous antibiotics

Answer

Acetaminophen

Question 10

What is the most likely diagnosis of this case?

Accepted Answer

Gout

Answer

Osteomyelitis

Answer

Vasculitis

Answer

Rheumatoid Arthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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