Rheumatology and Immunology Practice Questions

Q: Non-erosive arthritis is seen in which of the following conditions?

Systemic lupus erythematosus. **Explanation:** The hallmark of arthritis in **Systemic Lupus Erythematosus (SLE)** is that it is typically **non-erosive** [1]. While SLE patients frequently present with symmetrical polyarthritis (often involving small joints of the hands), the underlying pathology involves synovial inflammation without the destruction of bone or cartilage. A classic manifestation is **Jaccoud’s arthropathy**, where reversible deformities (like ulnar deviation or swan-neck) occur due to ligamentous laxity rather than joint surface erosion. On X-ray, the joint spaces remain preserved. **Analysis of Incorrect Options:** * **Ankylosing Spondylitis:** This is a seronegative spondyloarthropathy characterized by **erosive changes**, particularly at the sacroiliac joints (sacroiliitis) [1], eventually leading to bony ankylosis (fusion) and the "Bamboo spine" appearance. * **Rheumatic Fever:** While the arthritis in Rheumatic Fever is "migratory" and leaves no permanent damage, it is typically an acute, transient febrile polyarthritis. However, in the context of chronic connective tissue diseases and NEET-PG patterns, SLE is the classic prototype for "non-erosive" chronic arthritis. * **Juvenile Idiopathic Arthritis (JIA):** Most subtypes of JIA (especially polyarticular and systemic) are associated with **joint destruction and erosions** if not managed aggressively [2], leading to growth disturbances and permanent joint damage. **High-Yield Clinical Pearls for NEET-PG:** * **Jaccoud’s Arthropathy:** Reversible joint deformities in SLE (non-erosive) vs. **Rheumatoid Arthritis** (irreversible, erosive). * **Rhupus Syndrome:** A rare overlap of SLE and Rheumatoid Arthritis where erosive changes *can* occur. * **Most common joint involved in SLE:** Proximal Interphalangeal (PIP) joints and Metacarpophalangeal (MCP) joints. * **Radiology Tip:** If a question mentions "deformity without erosions," always think SLE.

Q: In rheumatoid arthritis, which part of the spinal column is typically involved?

Cervical. **Explanation:** Rheumatoid Arthritis (RA) is a chronic inflammatory systemic disease primarily characterized by **synovitis** (inflammation of the synovial membrane). The spinal column is unique in its anatomy; while most of the spine consists of fibrocartilaginous joints (intervertebral discs), the **Cervical Spine** is rich in **synovial joints**. These include the **atlanto-axial (C1-C2) joint**, the facet joints (zygapophyseal joints), and the joints of Luschka. Because RA specifically targets synovial tissue, the cervical spine is the most common (and often only) site of spinal involvement. * **Why Cervical is Correct:** The C1-C2 complex is purely synovial. Inflammation leads to the destruction of the transverse ligament and pannus formation, resulting in **Atlanto-axial subluxation**, a potentially life-threatening complication due to cord compression. * **Why Dorsal, Lumbar, and Sacral are Incorrect:** These regions are rarely involved in RA because they lack the high density of synovial joints found in the neck. Involvement of the lower spine is more characteristic of **Seronegative Spondyloarthropathies** (like Ankylosing Spondylitis), which target the entheses and sacroiliac joints, rather than the synovium. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common cervical deformity:** Anterior atlanto-axial subluxation. 2. **Radiological Hallmark:** Increased **ADI (Atlantodental Interval)**. In adults, an ADI >3mm suggests instability; >9mm indicates a high risk for neurological deficit. 3. **Pre-operative Caution:** Always obtain cervical spine X-rays (flexion/extension views) for RA patients undergoing any surgery to avoid catastrophic cord injury during intubation. 4. **Subaxial Subluxation:** "Stepladder appearance" on lateral X-ray due to multiple levels of vertebral slippage.

Q: Which of the following is the most specific test for rheumatoid arthritis?

Anti-MCV antibody. **Explanation:** The diagnosis of Rheumatoid Arthritis (RA) relies on identifying specific autoantibodies. While **Rheumatoid Factor (RF)** is the most sensitive initial test, it lacks specificity. The most specific markers for RA are antibodies against citrullinated proteins. **Why Anti-MCV is correct:** **Anti-MCV (Mutated Citrullinated Vimentin)** antibody is a type of Anti-Citrullinated Protein Antibody (ACPA). It has a **specificity of approximately 95-98%** for RA, which is comparable to or slightly higher than the standard Anti-CCP test. Clinically, Anti-MCV is highly significant because it correlates strongly with **disease activity** and the development of **radiographic joint damage** (erosions). In the context of this question, it is the only RA-specific marker listed. **Analysis of Incorrect Options:** * **B. Anti-cardiolipin antibody:** Associated with **Antiphospholipid Antibody Syndrome (APS)** and Systemic Lupus Erythematosus (SLE). It is linked to arterial/venous thrombosis and pregnancy loss. * **C. Anti-Mi-2 antibody:** A highly specific marker for **Dermatomyositis**. It is typically associated with a good prognosis and classic skin findings like Gottron’s papules. * **D. Anti-Ro (SS-A) antibody:** Primarily associated with **Sjögren’s syndrome** and SLE [1]. It is also linked to neonatal lupus and congenital heart block. **NEET-PG High-Yield Pearls:** * **Most Sensitive Test for RA:** Rheumatoid Factor (RF). * **Most Specific Test for RA:** Anti-CCP or Anti-MCV (ACPAs). * **Prognostic Value:** High titers of ACPA/Anti-MCV indicate a more aggressive, erosive disease course. * **Seronegative RA:** Refers to patients who have clinical RA but test negative for both RF and ACPAs [2].

Q: Circinate balanitis is a feature of which of the following conditions?

Reactive arthritis. **Explanation:** **Reactive Arthritis (ReA)** is the correct answer. It is a sterile inflammatory spondyloarthropathy that typically follows a gastrointestinal (e.g., *Salmonella, Shigella, Campylobacter*) or urogenital (e.g., *Chlamydia trachomatis*) infection [2]. **Circinate balanitis** is a pathognomonic cutaneous manifestation of ReA, characterized by painless, erythematous, superficial erosions with serpiginous borders on the glans penis [1], [2]. It occurs in approximately 20–40% of male patients with ReA [2]. **Analysis of Incorrect Options:** * **A. Osteoarthritis:** This is a degenerative joint disease characterized by cartilage loss and osteophyte formation; it does not involve systemic inflammatory or mucocutaneous lesions. * **B. Psoriatic Arthritis:** While it shares features like dactylitis and uveitis, its classic skin finding is plaque psoriasis. While "psoriasiform" lesions occur in ReA (Keratoderma blennorrhagicum), circinate balanitis is specifically linked to the triad of ReA [2]. * **D. Ankylosing Spondylitis:** Although it is the prototype of seronegative spondyloarthropathies, it primarily presents with sacroiliitis and inflammatory back pain rather than specific penile lesions. **High-Yield Clinical Pearls for NEET-PG:** * **Reiter’s Triad:** "Can't see (Uveitis/Conjunctivitis), can't pee (Urethritis), and can't climb a tree (Arthritis)." * **Keratoderma Blennorrhagicum:** Hyperkeratotic skin lesions on the palms and soles, histologically indistinguishable from pustular psoriasis [2]. * **HLA-B27 Association:** Strongly positive in 60–80% of cases [1]. * **Joint Involvement:** Typically an asymmetric oligoarthritis affecting the lower limbs (knees and ankles) [2].

Q: A 30-year-old male presents with numbness of both lower limbs and right upper limb. Examination reveals pulse 88/min and BP 160/110 mmHg. He also has digital gangrene involving the right 2nd and 3rd fingers. Urine routine examination is unremarkable. Microscopic examination shows RBCs. Hemogram and serum biochemistry are within normal limits. What is the most probable diagnosis?

Polyarteritis nodosa. **Explanation:** The clinical presentation of **Polyarteritis Nodosa (PAN)** is characterized by a "multi-system involvement" [1] that typically spares the lungs. This case highlights the classic triad of PAN: **Mononeuritis multiplex** (asymmetric numbness/nerve involvement), **Renovascular hypertension** (BP 160/110 mmHg), and **Cutaneous ischemia/gangrene**. 1. **Why PAN is correct:** PAN is a necrotizing vasculitis of medium-sized arteries [1]. It frequently involves the renal arteries (causing hypertension due to activation of the RAAS) and the vasa nervorum (causing mononeuritis multiplex). Crucially, PAN **spares the glomeruli**; therefore, while it causes renal artery narrowing or microaneurysms (leading to hematuria), it does **not** typically cause glomerulonephritis (no RBC casts or significant proteinuria), which matches the "unremarkable" urine routine mentioned. 2. **Why other options are incorrect:** * **SLE:** Usually presents with malar rash, arthritis, and significant proteinuria/casts (lupus nephritis), which are absent here. * **Malignant Hypertension:** While it explains high BP and some neurological symptoms, it does not explain asymmetric mononeuritis or digital gangrene in a 30-year-old without a primary cause. * **Churg-Strauss (EGPA):** This is a small-vessel vasculitis characterized by asthma, eosinophilia, and pulmonary infiltrates [2], none of which are present in this patient. **High-Yield Clinical Pearls for NEET-PG:** * **PAN Association:** Strongly associated with **Hepatitis B** (HBV) surface antigenemia (10–30% of cases). * **Imaging Gold Standard:** Digital Subtraction Angiography (DSA) showing **"string of beads"** appearance (microaneurysms). * **Key Negative:** PAN is **ANCA-negative** and characteristically **spares the lungs**. * **Treatment:** Corticosteroids and Cyclophosphamide; treat HBV if present [2].

Q: A 40-year-old female presents with a history of fever, weight loss, and polyarthralgia. Given the radiological findings, what is the most likely diagnosis?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - **Symmetric joint space narrowing** and **marginal erosions** at MCP/PIP joints with **periarticular osteopenia** are characteristic radiological findings of RA in a 40-year-old female. - The combination of **fever**, **weight loss**, and **polyarthralgia** reflects the **systemic inflammatory nature** of rheumatoid arthritis. *Osteoarthritis* - Radiological findings would show **osteophytes** and **joint space narrowing** primarily affecting **DIP joints**, not the pattern described. - Lacks **systemic symptoms** like fever and weight loss, typically presenting with **mechanical pain** in older patients. *Gout* - Characterized by **asymmetric punched-out erosions** with **overhanging edges** and possible **tophi**, not symmetric marginal erosions. - Typically affects the **first metatarsophalangeal joint** initially and lacks the systemic inflammatory features described. *Psoriatic arthritis* - Shows distinctive **pencil-in-cup deformity** and **asymmetric joint involvement**, often affecting **DIP joints** with **psoriatic skin lesions**. - Lacks the **symmetric pattern** and **periarticular osteopenia** characteristic of the described radiological findings.

Q: Strawberry gingivitis is classically seen in which of the following conditions?

Granulomatosis with polyangiitis. **Explanation:** **Granulomatosis with Polyangiitis (GPA)**, formerly known as Wegener’s Granulomatosis, is a small-vessel vasculitis characterized by a triad of upper respiratory tract, lower respiratory tract, and renal involvement. **Strawberry gingivitis** is a pathognomonic clinical sign of GPA. It manifests as erythematous, granular, and friable swelling of the gingiva with petechial hemorrhages, resembling the surface of a strawberry. This occurs due to necrotizing granulomatous inflammation of the oral mucosa. **Analysis of Incorrect Options:** * **Goodpasture Syndrome:** This is an anti-GBM antibody disease characterized by the duo of pulmonary hemorrhage and glomerulonephritis. It does not typically involve the upper airway or oral mucosa. * **Classic Polyarteritis Nodosa (PAN):** A medium-vessel vasculitis associated with Hepatitis B. It involves the skin (livedo reticularis), nerves (mononeuritis multiplex), and kidneys (microaneurysms), but characteristically **spares the lungs** and does not cause strawberry gingivitis. * **Kawasaki Syndrome:** While it presents with oral findings like a "strawberry tongue" (inflamed papillae) and cracked red lips, it does not cause "strawberry gingivitis" (gingival hyperplasia/petechiae). **NEET-PG High-Yield Pearls:** * **Serology:** GPA is strongly associated with **c-ANCA (PR3-ANCA)**. * **Classic Triad:** Sinusitis (saddle nose deformity), Hemoptysis (cavitary lesions), and Hematuria (RPGN). * **Histology:** Look for "Geographic necrosis" and poorly formed granulomas. * **Treatment:** Induction with Corticosteroids + Cyclophosphamide (or Rituximab).

Q: Pseudolymphoma is a known association with which of the following conditions?

Sjogren's syndrome. **Explanation:** **Sjogren’s syndrome (SS)** is the correct answer because it is characterized by a chronic, progressive infiltration of exocrine glands by lymphocytes (primarily B and T cells). In some patients, this lymphocytic proliferation becomes so intense that it mimics a malignant lymphoma histologically and clinically, a condition termed **Pseudolymphoma**. * **Mechanism:** In SS, there is chronic B-cell hyperactivity. Pseudolymphoma represents an intermediate stage in the multistep process of lymphoproliferation, situated between benign inflammatory infiltration and frank **B-cell Non-Hodgkin Lymphoma (NHL)**. Patients with SS have a **44-fold increased risk** of developing lymphoma (most commonly MALToma). **Analysis of Incorrect Options:** * **B. Systemic Lupus Erythematosus (SLE):** While SLE is associated with lymphadenopathy and an increased risk of malignancy, "Pseudolymphoma" is not a classic or defining association. * **C. Mixed Connective Tissue Disease (MCTD):** MCTD features overlapping symptoms of SLE, systemic sclerosis, and myositis, commonly presenting with synovitis and hand edema [1]. However, it does not typically present with the specific lymphoproliferative "pseudolymphoma" seen in Sjogren's. * **D. Behcet’s Syndrome:** This is a systemic vasculitis characterized by oral/genital ulcers and uveitis; it is not associated with pseudolymphomatous proliferation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common lymphoma in Sjogren’s:** MALT lymphoma (Mucosa-Associated Lymphoid Tissue), often involving the parotid gland. * **Predictors of Lymphoma in SS:** Persistent parotid swelling, purpura, leukopenia, low C4 levels, and mixed cryoglobulinemia. * **Schirmer’s Test:** Used for diagnosis (positive if <5 mm wetting in 5 minutes). * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are the hallmark serological markers.

Question 1

A 50-year-old female presented with mild to moderate unilateral headache which becomes severe occasionally along with fever, jaw pain and visual disturbances, malaise, fatigue and weight loss. On examination, scalp tenderness was noted. Lab findings revealed normocytic normochromic anemia, elevated ESR and raised ANA titers. A biopsy was taken from the temporal artery. Which of the following cells are most importantly involved in the pathogenesis of the above disease?

Accepted Answer

CD4 T cells

Answer

CD8 T cells

Answer

B cells

Answer

Dendritic cells

Question 2

Non-erosive arthritis is seen in which of the following conditions?

Accepted Answer

Systemic lupus erythematosus

Answer

Ankylosing spondylitis

Answer

Rheumatic fever

Answer

Juvenile Idiopathic Arthritis

Question 3

A 54-year-old man with a history of smoking presents with fever, hemoptysis, weight loss, and oligoarthritis. Serial skiagrams show fleeting opacities. What is the diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Allergic Bronchopulmonary aspergillosis

Answer

Sarcoidosis

Answer

Tuberculosis

Question 4

In rheumatoid arthritis, which part of the spinal column is typically involved?

Accepted Answer

Cervical

Answer

Dorsal

Answer

Lumbar

Answer

Sacral

Question 5

Which of the following is the most specific test for rheumatoid arthritis?

Accepted Answer

Anti-MCV antibody

Answer

Anti-cardiolipin antibody

Answer

Anti-Mi-2 antibody

Answer

Anti-Ro antibody

Question 6

Circinate balanitis is a feature of which of the following conditions?

Accepted Answer

Reactive arthritis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Answer

Ankylosing spondylitis

Question 7

A 30-year-old male presents with numbness of both lower limbs and right upper limb. Examination reveals pulse 88/min and BP 160/110 mmHg. He also has digital gangrene involving the right 2nd and 3rd fingers. Urine routine examination is unremarkable. Microscopic examination shows RBCs. Hemogram and serum biochemistry are within normal limits. What is the most probable diagnosis?

Accepted Answer

Polyarteritis nodosa

Answer

Systemic lupus erythematosus

Answer

Malignant hypertension

Answer

Churg-Strauss syndrome

Question 8

A 40-year-old female presents with a history of fever, weight loss, and polyarthralgia. Given the radiological findings, what is the most likely diagnosis?

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Gout

Answer

Psoriatic arthritis

Question 9

Strawberry gingivitis is classically seen in which of the following conditions?

Accepted Answer

Granulomatosis with polyangiitis

Answer

Goodpasture syndrome

Answer

Classic polyarteritis nodosa

Answer

Kawasaki syndrome

Question 10

Pseudolymphoma is a known association with which of the following conditions?

Accepted Answer

Sjogren's syndrome

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Mixed connective tissue disease

Answer

Behcet's syndrome

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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