Rheumatology and Immunology Practice Questions

Q: Which of the following is NOT a feature of Ankylosing spondylitis (AS)?

The Roos test is used to test for Sacroiliitis.. Explanation: 1. Why Option C is the correct answer (The False Statement): The Roos test (also known as the "Elevated Arm Stress Test") is used to diagnose Thoracic Outlet Syndrome, not sacroiliitis. It involves the patient repeatedly opening and closing their hands with arms abducted and elbows flexed for 3 minutes. Sacroiliitis in AS is typically assessed using the Schober’s test (for lumbar spine mobility) or the FABER (Patrick’s) test and Gaenslen’s test (for sacroiliac joint pain). 2. Analysis of Incorrect Options (True Features of AS): * Options A & B: The pathogenesis of AS is unique because it involves a progression from inflammation to fibrous ankylosis, which eventually undergoes ossification [1] to become bony ankylosis [3]. This leads to the characteristic "fused" or "bamboo spine" [3]. * Option D: Marginal syndesmophytes are a hallmark radiographic feature of AS [3]. These are thin, vertical bony outgrowths that bridge the vertebral bodies, resulting from the ossification of the outer fibers of the annulus fibrosus [1]. (Note: Non-marginal syndesmophytes are seen in Psoriatic Arthritis [3]). Clinical Pearls for NEET-PG: * HLA-B27: Strongly associated (>90% of cases) but not diagnostic [2]. * Earliest Sign: Sacroiliitis (usually bilateral and symmetrical) is the earliest radiographic change [1]. * Extra-articular manifestation: Acute Anterior Uveitis is the most common (unilateral, painful, red eye) [2]. * Modified New York Criteria: The gold standard for diagnosis, requiring both clinical and radiological evidence [3]. * Treatment of Choice: NSAIDs are first-line; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Q: A 35-year-old man presents with acute onset of pain, swelling, and redness of his right big toe as shown in the image. What is the most likely diagnosis?

Gout. ***Gout*** - **Acute monoarthritis** of the **first metatarsophalangeal joint** (big toe) with **erythema** and **swelling** is the classic presentation of **podagra**, the hallmark of gout. - **Sudden onset** pain and inflammation in the big toe, especially in men aged 30-50, strongly suggests **uric acid crystal deposition** causing acute gouty arthritis. *Cellulitis* - Would present with **spreading erythema** and **warmth** extending beyond the joint boundaries, often with **lymphangitis** or **fever**. - Typically affects **soft tissues** rather than causing discrete joint swelling, and pain would be more **diffuse** rather than localized to the joint. *Deep vein thrombosis* - Primarily affects **leg veins** causing **calf pain** and swelling, not isolated **toe joint involvement**. - Presents with **unilateral leg edema**, **warmth**, and **positive Homan's sign**, which are absent in this case. *Polyarteritis nodosa* - A **systemic vasculitis** affecting **medium-sized arteries** with multi-organ involvement including skin, kidneys, and nerves. - Would present with **systemic symptoms** like fever, weight loss, and **multiple organ dysfunction**, not isolated joint inflammation.

Q: Which of the following is FALSE about Sjögren's syndrome?

Parotid gland biopsy is preferred. Sjögren's syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of exocrine glands, primarily the lacrimal and salivary glands. **Why Option C is the Correct (False) Statement:** While the parotid gland is frequently enlarged in Sjögren's syndrome, a **minor salivary gland biopsy (usually from the lower lip)** is the preferred diagnostic procedure. It is less invasive, carries a lower risk of facial nerve injury or salivary fistula formation, and provides the characteristic "focus score" (≥1 focus of 50 lymphocytes per 4 $mm^2$ of tissue) required for classification criteria. **Analysis of Other Options:** * **Option A (True):** Keratoconjunctivitis sicca (dry eyes) results from lymphocytic infiltration of the lacrimal glands, leading to decreased tear production and corneal damage. * **Option B (True):** The hallmark histopathology of Sjögren's is a progressive **periductal and perivascular lymphocytic infiltration** (predominantly CD4+ T cells), which eventually leads to acinar atrophy and fibrosis. * **Option C (True):** Patients with Sjögren's have a 40-fold increased risk of developing B-cell lymphomas. The most common type is **MALToma** (Mucosa-Associated Lymphoid Tissue lymphoma), typically occurring in the parotid glands. **High-Yield Clinical Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) and Anti-La (SS-B) are the most specific markers. * **Schirmer’s Test:** Used to quantify tear production (<5 mm in 5 minutes is positive). * **Extraglandular Manifestations:** Include Raynaud’s phenomenon, cutaneous vasculitis, and interstitial lung disease. * **Risk Factor for Lymphoma:** Persistent parotid enlargement, purpura, and low C4 levels are warning signs of malignant transformation.

Q: The deformity shown in the image is characteristic of which condition?

Rheumatoid arthritis. ***Rheumatoid arthritis*** - Characteristic hand deformities include **ulnar deviation**, **swan neck deformity**, and **boutonnière deformity** due to chronic synovial inflammation affecting ligaments and tendons. - These deformities result from **erosive joint destruction** and **tendon rupture/displacement**, particularly affecting the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints. *Osteoarthritis* - Presents with **Heberden's nodes** (DIP joints) and **Bouchard's nodes** (PIP joints), which are bony enlargements rather than the soft tissue deformities seen in RA. - Typically causes **joint space narrowing** and **osteophyte formation** but does not produce ulnar deviation or swan neck deformities. *Ankylosing spondylitis* - Primarily affects the **axial skeleton** (spine and sacroiliac joints) with characteristic **bamboo spine** appearance on X-ray. - Hand involvement is **rare** and when present, does not cause the classic deformities associated with rheumatoid arthritis. *Psoriatic arthritis* - Characterized by **pencil-in-cup deformity** and **sausage-shaped digits (dactylitis)** due to enthesitis and tenosynovitis. - Often shows **asymmetric joint involvement** and **nail pitting**, distinct from the symmetric hand deformities of rheumatoid arthritis.

Question 1

A 30-year-old man presents with a 4-day history of cramping abdominal pain and bloody diarrhea. Physical examination reveals diffuse abdominal tenderness, normal bowel sounds, and no masses or organomegaly. Stool culture is positive for Shigella flexneri. The episode resolves spontaneously within one week. Six weeks later, he develops severe lower back pain, lumbar spine stiffness, and sacroiliac joint tenderness, treated with nonsteroidal anti-inflammatory agents. Two months after that, the back pain recurs, accompanied by right eye redness and blurred vision. Serologic testing for which of the following is most likely to be positive in this patient?

Accepted Answer

HLA-B27

Answer

Borrelia burgdorferi

Answer

Chlamydia trachomatis

Answer

Epstein-Barr virus

Question 2

A 70-year-old retired military person with a good previous medical record complains of bi-temporal headache which is decreased in the lying down position. He states that he gets relief by applying pressure over the bilateral temples. The patient also complains of loss of appetite with a feverish feeling. What is the diagnosis?

Accepted Answer

Chronic tension headache

Answer

Temporal arteritis

Answer

Migraine

Answer

Fibromyalgia

Question 3

Which of the following statements about polyarteritis nodosa (PAN) is FALSE?

Accepted Answer

PAN does not involve pulmonary arteries and bronchial vessels.

Answer

It is a necrotizing vasculitis of small and medium-sized muscular arteries.

Answer

Involvement of the renal and visceral arteries is characteristic.

Answer

Granulomas, significant eosinophilia, and are not observed.

Question 4

Which of the following is NOT a feature of Ankylosing spondylitis (AS)?

Accepted Answer

The Roos test is used to test for Sacroiliitis.

Answer

Fibrous ankylosis is part of the pathogenesis of AS.

Answer

Bony ankylosis is part of the pathogenesis of AS.

Answer

Marginal syndesmophytes are seen on X-ray.

Question 5

A 35-year-old man presents with acute onset of pain, swelling, and redness of his right big toe as shown in the image. What is the most likely diagnosis?

Accepted Answer

Gout

Answer

Cellulitis

Answer

Deep vein thrombosis

Answer

Polyarteritis nodosa

Question 6

A patient presents with melaena, normal renal function, hypertension, and mononeuritis multiplex. What is the most probable diagnosis?

Accepted Answer

Classical polyarteritis nodosa

Answer

Microscopic polyangiitis

Answer

Henoch-Schonlein purpura

Answer

Buerger's disease

Question 7

A patient with primary Sjogren syndrome treated with tear replacement for symptomatic relief notes continued parotid swelling for the last 3 months. She also has enlarged posterior cervical lymph nodes. Evaluation shows leukopenia and low C4 complement levels. What is the most likely diagnosis?

Accepted Answer

Lymphoma

Answer

Amyloidosis

Answer

Chronic pancreatitis

Answer

HIV infection

Question 8

A 25-year-old male presented to the OPD with a complaint of recurrent oral ulcers and congested eyes. On enquiry, he has a history of prior hospital admission for venous thrombosis. What is the condition he is suffering from?

Accepted Answer

Behcet's disease

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Reiter's syndrome

Answer

Wegener's Granulomatosis

Question 9

Which of the following is FALSE about Sjögren's syndrome?

Accepted Answer

Parotid gland biopsy is preferred

Answer

Keratoconjunctivitis sicca

Answer

Periductal and perivascular lymphocytic infiltration

Answer

MALToma is the most common lymphoma

Question 10

The deformity shown in the image is characteristic of which condition?

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Ankylosing spondylitis

Answer

Psoriatic arthritis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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