Rheumatology and Immunology Practice Questions

Q: A 57-year-old man, previously asymptomatic and on no medications, develops a painful left big toe. It is so painful that even the weight of his sheets is excruciating. On examination, there is a swollen red toe. Which of the following medications is relatively contraindicated?

allopurinol. **Explanation:** The clinical presentation of sudden, excruciating pain, redness, and swelling in the first metatarsophalangeal joint (podagra) is classic for **Acute Gouty Arthritis** [2]. **Why Allopurinol is the Correct Answer:** Allopurinol is a Xanthine Oxidase Inhibitor used for chronic urate-lowering therapy (ULT) [1]. However, it is **relatively contraindicated during an acute attack** if the patient is not already taking it. Initiating allopurinol during an acute flare causes a rapid fluctuation in serum uric acid levels, leading to the mobilization of urate crystals from tissue stores into the joint space. This "crystal shedding" can significantly worsen the existing inflammation or prolong the duration of the attack [1]. **Analysis of Incorrect Options:** * **A & C (Indomethacin and Ibuprofen):** Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the first-line treatment for acute gout [1]. They work by inhibiting prostaglandin synthesis to reduce pain and inflammation. * **B (Colchicine):** This is another first-line agent for acute gout [1]. It works by inhibiting microtubule polymerization and leukocyte chemotaxis, thereby halting the inflammatory response to urate crystals. **High-Yield Clinical Pearls for NEET-PG:** 1. **Management Strategy:** Treat the acute attack first (NSAIDs, Colchicine, or Steroids). Wait **2–4 weeks** after the symptoms have completely resolved before initiating Allopurinol. 2. **Exception:** If a patient is *already* on Allopurinol when an acute attack occurs, **do not stop it**. Continue the maintenance dose and add anti-inflammatory agents. 3. **Prophylaxis:** When starting Allopurinol, always co-prescribe low-dose Colchicine or NSAIDs for 3–6 months to prevent mobilization flares [1]. 4. **Gold Standard Diagnosis:** Arthrocentesis showing **needle-shaped, negatively birefringent** monosodium urate crystals under polarized light.

Q: Which of the following is NOT true about ankylosing spondylitis?

90% of patients are HLA-B27 positive.. Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy primarily affecting the axial skeleton. **Explanation of the Correct Answer:** Option **C** is the incorrect statement (and thus the correct answer) because while there is a strong association between HLA-B27 and AS, the prevalence varies by ethnicity. In the Indian population and globally, approximately **90-95% of patients** with AS carry the HLA-B27 gene; however, the presence of the gene is **not diagnostic** on its own, as only 5% of HLA-B27 positive individuals actually develop the disease. In the context of NEET-PG, the "90%" figure is often used as a distractor because while true for the patient population, the diagnosis is primarily clinical and radiological (Modified New York Criteria). **Analysis of Other Options:** * **A. Gender:** AS shows a strong male predilection, traditionally cited as a **3:1 male-to-female ratio**. * **B. Age of Onset:** It typically presents in young adults, usually **late teens to the 3rd decade (20-30 years)**. Presentation after age 40 is rare. * **D. Bamboo Spine:** This is a classic late-stage radiographic finding caused by **syndesmophytes** (marginal ossification of the annulus fibrosus) and diffuse paraspinal ligamentous calcification, giving the spine a fused, rigid appearance. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** Symmetrical **Sacroiliitis** (best seen on MRI as bone marrow edema). * **Schober’s Test:** Used to clinically assess restricted lumbar flexion. * **Extra-articular manifestation:** **Acute Anterior Uveitis** is the most common. * **Radiology:** Look for "Dagger sign" (ossification of supraspinous/interspinous ligaments) and "Romanus lesions" (shiny corners of vertebrae). * **Treatment:** NSAIDs are the first-line; TNF-alpha inhibitors (e.g., Etanercept) are used for refractory cases.

Q: Which of the following statements is FALSE regarding HIV-related arthritis?

The hip is the commonest joint involved.. Explanation: HIV-associated arthritis encompasses several patterns of joint involvement, most commonly presenting as an asymmetric oligoarthritis. 1. Why Option D is the Correct (False) Statement: In HIV-related arthritis, the lower extremity joints are most frequently affected, specifically the knees and ankles. The hip is not the most common joint involved [2]. This pattern often mimics reactive arthritis but occurs in the context of HIV infection. 2. Analysis of Incorrect Options (True Statements): * Option A: Unlike classic Reactive Arthritis (ReA), HIV-associated reactive arthritis is frequently characterized by a lack of typical extra-articular manifestations like uveitis or the classic triad [2]. Cutaneous and mucosal lesions (like keratoderma blennorrhagicum) are notably rare in HIV patients compared to HIV-negative ReA patients. * Option B: While asymmetric oligoarthritis is the hallmark, a symmetrical polyarthritis resembling Rheumatoid Arthritis (but RF negative) can occur, particularly in the early stages of HIV infection or as part of the D diffuse infiltrative lymphocytosis syndrome (DILS). * Option C: Enthesopathy (inflammation where tendons/ligaments attach to bone) is a classic feature of Spondyloarthropathies [2]. However, in the specific subset of "HIV-associated arthritis," enthesopathy is relatively rare compared to its frequency in idiopathic Psoriatic Arthritis or Ankylosing Spondylitis. Clinical Pearls for NEET-PG: * HIV-Associated Arthritis: Usually short-lived (1–6 weeks), non-erosive, and involves the knees/ankles. * Psoriatic Arthritis: Is often more severe and extensive in HIV-positive patients than in the general population [1]. * Treatment Note: NSAIDs are first-line. While methotrexate is standard for RA, it must be used with extreme caution in HIV due to further immunosuppression; HAART often improves joint symptoms.

Q: In gout, tophi are typically found in which of the following locations?

Joint capsule. **Explanation:** Gout is a metabolic disorder characterized by hyperuricemia and the deposition of **monosodium urate (MSU) crystals** in and around joints. **Tophi** are pathognomonic clinical features of chronic tophaceous gout, representing large, chalky aggregations of urate crystals surrounded by an intense inflammatory granulomatous reaction. **Why the Joint Capsule is correct:** While MSU crystals initially deposit in the synovial membrane, chronic accumulation leads to the formation of tophi in the **periarticular soft tissues**, most notably the **joint capsule**, ligaments, and tendons. The joint capsule provides the structural environment where these deposits can enlarge significantly, often leading to joint deformity and bone erosions (punched-out lesions). **Analysis of Incorrect Options:** * **A. Synovial fluid:** While MSU crystals are found here during an acute attack (characteristically needle-shaped and negatively birefringent), they exist as free crystals, not as organized "tophi." * **B. Articular cartilage:** Crystals do deposit on the surface of the cartilage (causing the "double contour sign" on ultrasound), but the avascular nature of cartilage does not support the formation of large, granulomatous tophaceous masses. * **D. Skin:** Tophi are frequently seen *under* the skin (subcutaneous), particularly on the helix of the ear or olecranon bursa, but they originate in the underlying connective tissue or bursae rather than the skin layers themselves. **NEET-PG High-Yield Pearls:** * **Most common site for Tophi:** The helix of the ear and the Achilles tendon. * **First joint affected:** 1st Metatarsophalangeal joint (Podagra). * **Radiology:** Look for "Martel’s sign" or "G-pull sign" (overhanging edges of bone). * **Polarizing Microscopy:** MSU crystals show **strong negative birefringence** (yellow when parallel to the slow axis).

Q: Which one of the following disorders is not associated with carpal tunnel syndrome?

Addison's disease. Explanation: Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve as it passes through the carpal tunnel. It is typically caused by any condition that increases the volume of the contents within the tunnel or decreases the size of the tunnel itself. Why Addison’s Disease is the Correct Answer: Addison’s disease (primary adrenocortical insufficiency) is characterized by a deficiency of cortisol and aldosterone [1]. It typically leads to weight loss, dehydration, and volume depletion [1]. It does not cause the fluid retention, soft tissue hypertrophy, or deposition of metabolic byproducts necessary to compress the median nerve. Therefore, it is not associated with CTS. Analysis of Incorrect Options: * Diabetes Mellitus: This is a very common association. It causes CTS through multiple mechanisms, including increased glycosylation of collagen (leading to stiffening of the transverse carpal ligament) and a lower threshold for nerve compression due to underlying diabetic neuropathy. * Hypothyroidism: Myxedematous tissue (accumulation of glycosaminoglycans) and associated fluid retention cause increased pressure within the carpal tunnel. * Acromegaly: Excessive growth hormone leads to the overgrowth of soft tissues and bones, directly narrowing the carpal tunnel space. NEET-PG High-Yield Pearls: * Most common cause: Idiopathic. * Systemic associations (Mnemonic: ARTHRITIS): Amlyoidosis, Rheumatoid arthritis (synovitis), Trauma, Hypothyroidism, Retention of fluid (Pregnancy/CKD), Idiopathic, Tumors, Infection, Sugar (Diabetes). * Clinical Signs: Positive Phalen’s test and Tinel’s sign. * Gold Standard Diagnosis: Nerve Conduction Studies (NCS) showing delayed sensory/motor conduction across the wrist.

Q: Which of the following conditions is characterized by non-deforming arthritis?

Behcet's syndrome. **Explanation:** **Behcet’s Syndrome (Correct Answer):** Behcet’s syndrome is a multisystem inflammatory disorder characterized by the triad of oral ulcers, genital ulcers, and uveitis. Arthritis occurs in approximately 50% of patients, typically affecting large joints (knees and ankles). The key diagnostic feature of Behcet’s arthritis is that it is **non-deforming and non-erosive**, meaning it does not cause permanent joint destruction or radiological changes, despite recurrent inflammatory episodes. **Analysis of Incorrect Options:** * **Syphilis:** Late-stage syphilis (Tabes dorsalis) is associated with **Charcot’s joint** (neuropathic arthropathy). This is a severely deforming, destructive arthropathy resulting from the loss of pain sensation and proprioception. * **Osteoarthritis (OA):** OA is a degenerative joint disease characterized by the progressive loss of articular cartilage, subchondral sclerosis, and the formation of osteophytes. It is inherently **deforming**, leading to conditions like Heberden’s and Bouchard’s nodes. * **Psoriatic Arthritis (PsA):** PsA is an inflammatory seronegative spondyloarthropathy [2]. It is often **highly erosive and deforming**, classically presenting with "pencil-in-cup" deformities on X-ray and *arthritis mutilans* in severe cases [1]. **NEET-PG Clinical Pearls:** * **Non-deforming Arthritis "Club":** Besides Behcet’s, other classic conditions with non-deforming arthritis include **SLE** (though Jaccoud’s arthropathy can show reversible deformity), **Rheumatic Fever**, and **Henoch-Schönlein Purpura (HSP)**. * **Behcet’s Hallmark:** Look for the **Pathergy Test** (development of a papule/pustule 24-48 hours after a sterile needle prick), which is highly specific for this syndrome. * **HLA Association:** Behcet’s is strongly associated with **HLA-B51**.

Q: A 13-year-old female child presented with recurrent sinusitis, fever, arthralgia, respiratory distress, hematuria, and hypertension. Renal biopsy showed necrotizing granuloma. The anti-proteinase-3 ANCA was positive. What is the most likely diagnosis?

Wegener's granulomatosis. ### Explanation The clinical presentation of a triad involving the **upper respiratory tract** (sinusitis), **lower respiratory tract** (respiratory distress), and **kidneys** (hematuria, hypertension) is classic for **Granulomatosis with Polyangiitis (GPA)**, formerly known as **Wegener’s granulomatosis** [1]. **Why Option B is Correct:** * **Clinical Triad:** GPA typically affects the upper airway (90%), lungs, and kidneys (Pauci-immune glomerulonephritis). * **Pathology:** The presence of **necrotizing granulomas** on renal biopsy is a hallmark feature that distinguishes it from other small-vessel vasculitides. * **Serology:** **c-ANCA (anti-PR3)** is highly specific (approx. 90%) for GPA [2]. **Why Other Options are Incorrect:** * **A. Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis associated with Hepatitis B. It typically **spares the lungs** and does not involve granuloma formation or ANCA. * **C. Microscopic Polyangiitis (MPA):** Similar to GPA but **lacks granulomatous inflammation** and primarily involves **p-ANCA (anti-MPO)**. Upper airway involvement is rare. * **D. Churg-Strauss Syndrome (EGPA):** Characterized by **asthma, eosinophilia**, and p-ANCA [2]. While it involves granulomas, the absence of eosinophilia and the presence of anti-PR3 make it unlikely here. **High-Yield Pearls for NEET-PG:** 1. **GPA Serology:** c-ANCA (anti-Proteinase 3); **MPA/EGPA Serology:** p-ANCA (anti-Myeloperoxidase) [2]. 2. **Classic Sign:** "Saddle nose deformity" due to nasal cartilage destruction. 3. **Chest X-ray:** May show bilateral nodular infiltrates with cavitation. 4. **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab) [2].

Question 1

A 57-year-old man, previously asymptomatic and on no medications, develops a painful left big toe. It is so painful that even the weight of his sheets is excruciating. On examination, there is a swollen red toe. Which of the following medications is relatively contraindicated?

Accepted Answer

allopurinol

Answer

indomethacin

Answer

colchicine

Answer

ibuprofen

Question 2

Which of the following is NOT true about ankylosing spondylitis?

Accepted Answer

90% of patients are HLA-B27 positive.

Answer

Affects males more commonly than females.

Answer

Typically presents in the 30-40 year age group.

Answer

Radiographic findings may include a 'bamboo spine'.

Question 3

Which of the following statements is FALSE regarding HIV-related arthritis?

Accepted Answer

The hip is the commonest joint involved.

Answer

Cutaneous and mucosal lesions are rare.

Answer

Symmetrical polyarthritis can be seen.

Answer

Enthesopathy is rare.

Question 4

In gout, tophi are typically found in which of the following locations?

Accepted Answer

Joint capsule

Answer

Synovial fluid

Answer

Articular cartilage

Answer

Skin

Question 5

Which one of the following disorders is not associated with carpal tunnel syndrome?

Accepted Answer

Addison's disease

Answer

Diabetes mellitus

Answer

Hypothyroidism

Answer

Acromegaly

Question 6

Which of the following conditions is characterized by non-deforming arthritis?

Accepted Answer

Behcet's syndrome

Answer

Syphilis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Question 7

An 18-year-old boy presents with digital gangrene of the third and fourth fingers over the last 2 weeks. On examination, the blood pressure is 170/110 mm of Hg, and all peripheral pulses were palpable. Blood and urine examinations were unremarkable. ANA, Anti-dsDNA, and ANCA were negative. Which of the following represents the most likely diagnosis?

Accepted Answer

Polyarteritis nodosa

Answer

Wegener's granulomatosis

Answer

Takayasu's arteritis

Answer

Systemic lupus erythematosus (SLE)

Question 8

A 13-year-old female child presented with recurrent sinusitis, fever, arthralgia, respiratory distress, hematuria, and hypertension. Renal biopsy showed necrotizing granuloma. The anti-proteinase-3 ANCA was positive. What is the most likely diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Polyarteritis Nodosa

Answer

Microscopic polyangiitis

Answer

Churg-Strauss syndrome

Question 9

Which of the following statements is true about Rheumatoid arthritis?

Accepted Answer

Associated with adrenal hyperplasia

Answer

Involves peripheral joints more commonly than axial joints

Answer

Does not decrease life expectancy

Answer

Associated with vasculitis

Question 10

A 67-year-old man with lung cancer presents with progressive weakness in his arms and legs. He reports difficulty rising from a chair and climbing stairs, with no associated pain or discomfort. Physical examination reveals proximal muscle strength of four out of five in both upper and lower limbs. His reflexes, muscle tone, and sensation are normal. He also has a heliotrope rash on his eyelids and Gottron's papules on his knuckles. Based on these findings, what is the most likely anatomic site of the disorder causing his muscle weakness?

Accepted Answer

Muscle

Answer

Anterior horn cell

Answer

Peripheral nerve

Answer

Neuromuscular junction

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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