Rheumatology and Immunology Practice Questions

Q: A patient presents with gritty pain in the eye and joint pain, following a recent urinary tract infection. What is the most probable diagnosis?

Reiter's syndrome. ### Explanation **Correct Option: A. Reiter’s Syndrome (Reactive Arthritis)** Reiter’s syndrome is a clinical triad of **non-gonococcal urethritis, conjunctivitis (or uveitis), and arthritis** [1]. It is a type of Seronegative Spondyloarthropathy that typically follows an infection of the urogenital tract (e.g., *Chlamydia trachomatis*) or the gastrointestinal tract (e.g., *Salmonella*, *Shigella*) [1]. In this case, the "gritty pain in the eye" indicates conjunctivitis, and the joint pain following a urinary tract infection (UTI) fits the classic "Can't see, can't pee, can't climb a tree" mnemonic. **Why other options are incorrect:** * **B. Behçet’s Syndrome:** Characterized by the triad of oral ulcers, genital ulcers, and uveitis. While it involves the eyes and joints, it is not typically preceded by a UTI and is defined by painful aphthous ulcers. * **C. Sarcoidosis:** A multisystem granulomatous disease. While it can cause uveitis and arthritis (Lofgren’s syndrome), it usually presents with bilateral hilar lymphadenopathy and respiratory symptoms rather than a post-UTI onset. * **D. Systemic Lupus Erythematosus (SLE):** An autoimmune disease presenting with malar rash, photosensitivity, and polyarthritis. It does not typically follow an acute UTI and has a different clinical profile (ANA positivity). **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly associated with **HLA-B27** (approx. 80% of cases) [1]. * **Skin Findings:** Look for **Keratoderma blennorrhagicum** (vesicular, crusty lesions on palms/soles) and **Circinate balanitis** [1]. * **Joint Involvement:** Typically an asymmetric oligoarthritis affecting large joints of the lower extremities (e.g., knees, ankles) [1]. * **Dactylitis:** "Sausage digits" are a common feature.

Q: Which of the following conditions is associated with HLA-B27 in 90% of cases?

Ankylosing spondylitis. The association between Human Leukocyte Antigen (HLA) alleles and specific diseases is a high-yield topic for NEET-PG. **Ankylosing Spondylitis (AS)** shows the strongest association with **HLA-B27**, with approximately **90-95%** of patients testing positive for this marker [1]. AS is a chronic inflammatory arthritis primarily affecting the sacroiliac joints and the axial skeleton, leading to characteristic "bamboo spine" on imaging. **Analysis of Options:** * **Ankylosing Spondylitis (Correct):** The 90% association is a diagnostic hallmark. While HLA-B27 is present in only 8% of the general population, its presence significantly increases the relative risk of developing AS [1]. * **Rheumatoid Arthritis:** This is primarily associated with **HLA-DR4** (specifically the "shared epitope"). It is not linked to HLA-B27. * **Psoriasis:** While Psoriatic Arthritis is part of the seronegative spondyloarthropathy group, the association with HLA-B27 is much lower (around 40-50%). Psoriasis itself is more strongly linked to **HLA-Cw6**. * **Reiter’s Syndrome (Reactive Arthritis):** This condition is also associated with HLA-B27, but the prevalence is lower than in AS, typically ranging from **60% to 80%**. **Clinical Pearls for NEET-PG:** 1. **Seronegative Spondyloarthropathies (PEAR):** Remember the mnemonic **P**soriatic arthritis, **E**nteropathic arthritis, **A**nkylosing spondylitis, and **R**eactive arthritis. All are associated with HLA-B27 and are Rheumatoid Factor (RF) negative [1]. 2. **Schober’s Test:** Used clinically to assess the restriction of lumbar flexion in AS. 3. **Other HLA Associations:** * HLA-B51: Behcet’s disease. * HLA-DQ2/DQ8: Celiac disease. * HLA-DR3/DR4: Type 1 Diabetes Mellitus.

Q: Which of the following extra-articular manifestations of Rheumatoid Arthritis is associated with an increased frequency of infections?

Felty syndrome. **Explanation:** **Felty Syndrome (FS)** is the correct answer because it is characterized by the triad of **Rheumatoid Arthritis (RA), Splenomegaly, and Neutropenia.** [1] The profound neutropenia (absolute neutrophil count <2000/mm³) significantly impairs the body's primary defense against bacterial pathogens, leading to a high frequency of recurrent skin and respiratory infections. It typically occurs in patients with long-standing, seropositive, and erosive RA. [1] **Analysis of Incorrect Options:** * **Rheumatoid Vasculitis:** While a severe complication involving small-to-medium vessels (causing digital ischemia or ulcers), it is an inflammatory process rather than an infectious one. [2] * **Episcleritis:** This is a common, relatively benign ocular manifestation of RA. [2] It causes redness and irritation but does not predispose the patient to systemic or local infections. * **Sjogren Syndrome:** Secondary Sjogren’s is common in RA, leading to dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). [2] While it increases the risk of local dental caries or corneal abrasions, it does not carry the high systemic infection risk associated with the neutropenia of Felty syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Felty Syndrome Triad:** RA + Splenomegaly + Neutropenia. [1] * **Genetic Association:** Strongly linked with **HLA-DR4**. * **Large Granular Lymphocyte (LGL) Leukemia:** Often overlaps with Felty syndrome; both present with neutropenia and splenomegaly. * **Treatment:** Management of the underlying RA (usually with Methotrexate) often improves the neutrophil count. Granulocyte colony-stimulating factor (G-CSF) may be used in severe cases.

Q: Sacro-iliac joint involvement is common in which condition?

Ankylosing spondylitis. **Explanation:** **Ankylosing Spondylitis (AS)** is the correct answer because it is the prototypical seronegative spondyloarthropathy. The hallmark of AS is **bilateral, symmetrical sacroiliitis**, which is often the earliest clinical and radiological manifestation of the disease. It typically affects young males (HLA-B27 positive) and progresses to involve the entire spine, leading to the characteristic "Bamboo spine" appearance. **Analysis of Incorrect Options:** * **Rheumatoid Arthritis (RA):** This is a systemic inflammatory disease that primarily targets the small joints of the hands and feet (PIP and MCP joints). It characteristically **spares the sacroiliac joints** and the thoracolumbar spine, though it may involve the cervical spine (atlanto-axial subluxation). * **Reiter’s Syndrome (Reactive Arthritis):** While this is also a seronegative spondyloarthropathy that can involve the SI joint, the involvement is typically **asymmetric** and less frequent compared to the universal, symmetric involvement seen in AS. * **Osteoarthritis (OA):** This is a degenerative "wear and tear" disease. While it can affect the SI joint in elderly patients, it is not a primary or defining feature of the condition, which more commonly targets weight-bearing joints like the knees and hips. **Clinical Pearls for NEET-PG:** * **Schober’s Test:** Used to assess restricted lumbar flexion in AS. * **Radiological Signs:** Look for "Dagger sign" (ossification of supraspinous ligaments) and "Romanus lesions" (shiny corners of vertebrae). * **First-line Treatment:** NSAIDs are the mainstay for pain and stiffness; TNF-alpha inhibitors are used for refractory cases. * **Extra-articular manifestation:** The most common is **Acute Anterior Uveitis**.

Q: A patient presented with arthritis and purpura. Laboratory examination showed monoclonal and polyclonal cryoglobulins. Histopathology showed deposits of cryoglobulins around the vessels. The patient should be tested for which of the following infections?

HCV. The clinical presentation of arthritis, purpura, and the presence of both monoclonal and polyclonal cryoglobulins points directly to **Mixed Cryoglobulinemia (Type II).** 1. **Why HCV is correct:** Hepatitis C Virus (HCV) is the most common cause of Mixed Cryoglobulinemia, associated with over **90% of cases**. Chronic HCV infection leads to persistent immune stimulation, causing B-cell expansion and the production of cryoglobulins (immunoglobulins that precipitate at cold temperatures) [1]. These complexes deposit in small-to-medium vessels, leading to the classic triad of **Meltzer’s triad**: Palpable purpura, arthralgia, and asthenia (weakness). Histopathology typically reveals leukocytoclastic vasculitis with cryoglobulin deposits [1]. 2. **Why other options are incorrect:** * **HBV:** While HBV is strongly associated with **Polyarteritis Nodosa (PAN)**, it is a much less common cause of cryoglobulinemia compared to HCV. * **EBV:** EBV is associated with B-cell lymphomas and infectious mononucleosis, but not typically with symptomatic mixed cryoglobulinemia. * **Parvovirus B19:** This virus is famous for causing "slapped cheek" rash (Erythema infectiosum) and transient aplastic crisis. While it can cause acute arthritis mimicking RA, it does not cause cryoglobulinemic vasculitis. **High-Yield Clinical Pearls for NEET-PG:** * **Classification:** * **Type I:** Monoclonal (associated with Multiple Myeloma/Waldenström’s). * **Type II & III (Mixed):** Polyclonal IgG + Monoclonal/Polyclonal IgM (associated with HCV) [1]. * **Complement Levels:** Characteristically shows **low C4** levels with normal or slightly low C3. * **Renal Involvement:** Often presents as Membranoproliferative Glomerulonephritis (MPGN). * **Treatment:** Primarily involves treating the underlying HCV infection (Direct-acting antivirals) [1].

Q: Which of the following is NOT true about temporal arteritis?

Worsens on exposure to heat. Temporal Arteritis, also known as **Giant Cell Arteritis (GCA)**, is a large-vessel vasculitis that primarily involves the extracranial branches of the carotid artery. **Why Option C is the correct answer (False statement):** Temporal arteritis does **not** worsen with heat. In fact, patients often experience **scalp tenderness** so severe that they cannot brush their hair or lie on a pillow. A classic diagnostic sign is **jaw claudication** (pain while chewing), which is triggered by exertion of the masseter muscles, not by temperature changes. Heat sensitivity is more characteristic of conditions like Multiple Sclerosis (Uhthoff's phenomenon) or certain erythromelalgias. **Analysis of Incorrect Options (True statements):** * **Option A:** GCA is a medical emergency because it can cause **sudden, irreversible blindness** due to Anterior Ischemic Optic Neuropathy (AION). While it often starts unilaterally, it can rapidly become bilateral if untreated [1]. * **Option B:** There is a significant female predilection, with women being affected roughly 2–3 times more often than men. * **Option D:** It is almost exclusively a disease of the **elderly** (rarely seen before age 50), with the peak incidence occurring between ages 70 and 80. **Clinical Pearls for NEET-PG:** * **Association:** Strongly associated with **Polymyalgia Rheumatica (PMR)** in 50% of cases (proximal muscle pain/stiffness) [1]. * **Diagnosis:** Gold standard is **Temporal Artery Biopsy** (look for "skip lesions") [1]. * **Lab:** Characterized by a markedly elevated **ESR** (often >100 mm/hr) [1]. * **Management:** Do not wait for biopsy results; start **high-dose corticosteroids** immediately to prevent permanent vision loss [1].

Q: Which HLA is associated with Reiter syndrome?

HLA-B27. ***HLA-B27*** - **HLA-B27** is the major histocompatibility complex (MHC) class I allele strongly associated with **Reiter syndrome** (now termed **Reactive Arthritis**) a component of the **seronegative spondyloarthropathies** [1]. - Approximately 60-80% of patients with Reactive Arthritis who present with the classic triad (urethritis, conjunctivitis, arthritis) are positive for **HLA-B27** [1]. *HLA-DR3* - **HLA-DR3** is primarily associated with several autoimmune disorders, including **Celiac Disease**, **Graves' Disease**, and **Systemic Lupus Erythematosus** (SLE). - It is an MHC class II allele, distinguishing it from the MHC class I linkage observed in Reactive Arthritis. *HLA-DQ8* - **HLA-DQ8** (often with HLA-DQ2) is a key genetic risk factor for **Celiac Disease**, playing a role in presenting gliadin peptides to T cells. - This allele is also associated with **Type 1 Diabetes Mellitus** but lacks a significant established association with the pathogenesis of the spondyloarthropathies. *HLA-DR4* - **HLA-DR4** carries the strongest genetic risk for **Rheumatoid Arthritis** (RA), particularly in individuals prone to developing severe, erosive disease. - While associated with generalized autoimmunity, **HLA-DR4** is not the primary marker for the seronegative spondyloarthropathies like Reactive Arthritis [2].

Q: What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?

Uveitis. ***Uveitis***- **Anterior uveitis** (or iritis) is the most common ocular manifestation associated with **HLA-B27 positive spondyloarthropathies** (like ankylosing spondylitis), which frequently co-occur with **ulcerative colitis** (UC) [1].- This association highlights a shared inflammatory pathway between the gut, joints, and eyes, typical of **extra-intestinal manifestations of IBD** [2]. *Conjunctivitis*- **Conjunctivitis** is a non-specific, less severe eye manifestation sometimes seen in IBD, but it does not carry the strong, specific association with the **HLA-B27** genotype.- It typically involves inflammation of the conjunctiva and is generally self-limiting, unlike the vision-threatening nature of uveitis.*Scleritis*- **Scleritis** involves painful, severe inflammation of the sclera and is a less frequent, though severe, ocular complication of IBD.- While associated with UC, scleritis is clinically distinct from uveitis and is more strongly linked to systemic vasculitides like **Polyarteritis Nodosa** or **Rheumatoid Arthritis** rather than the primary HLA-B27/IBD link.*Iridocyclitis*- **Iridocyclitis** is anatomically synonymous with **anterior uveitis**, describing inflammation of the iris and ciliary body.- As **Uveitis** is the standard, encompassing term used in MCQs for the classic HLA-B27 associated ocular pathology, it is the best fit, even though iridocyclitis describes the pathology precisely.

Question 1

A patient presents with gritty pain in the eye and joint pain, following a recent urinary tract infection. What is the most probable diagnosis?

Accepted Answer

Reiter's syndrome

Answer

Behçet's syndrome

Answer

Sarcoidosis

Answer

Systemic Lupus Erythematosus

Question 2

Which of the following conditions is associated with HLA-B27 in 90% of cases?

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

Psoriasis

Answer

Reiter's syndrome

Question 3

Which of the following extra-articular manifestations of Rheumatoid Arthritis is associated with an increased frequency of infections?

Accepted Answer

Felty syndrome

Answer

Rheumatoid vasculitis

Answer

Episcleritis

Answer

Sjogren syndrome

Question 4

Sacro-iliac joint involvement is common in which condition?

Accepted Answer

Ankylosing spondylitis

Answer

Rheumatoid arthritis

Answer

Reiter's syndrome

Answer

Osteoarthritis

Question 5

A patient presented with arthritis and purpura. Laboratory examination showed monoclonal and polyclonal cryoglobulins. Histopathology showed deposits of cryoglobulins around the vessels. The patient should be tested for which of the following infections?

Accepted Answer

HCV

Answer

HBV

Answer

EBV

Answer

Parvovirus

Question 6

A 40-year-old man presents with a 2-week history of recurrent oral ulcers, genital ulcers, intermittent arthritic pain of the knees, and abdominal pain. Physical examination reveals shallow ulcerations of the mucosa of the glans penis, as well as oral aphthous ulcers and conjunctivitis. Which of the following is the most likely diagnosis?

Accepted Answer

Behçet disease

Answer

Genital herpes

Answer

Gonorrhea

Answer

Polyarteritis nodosa

Question 7

A 45-year-old woman complains of severe headaches and difficulty in swallowing. Over the past 6 months, she has noticed small, red lesions around her mouth as well as thickening of her skin. The patient has "stone facies" on physical examination. Which of the following antigens is the most common and most specific target of autoantibody in patients with this disease?

Accepted Answer

Scl-70 (anti-topoisomerase I)

Answer

C-ANCA (anti-proteinase-3)

Answer

Double-stranded DNA

Answer

P-ANCA (anti-myeloperoxidase)

Question 8

Which of the following is NOT true about temporal arteritis?

Accepted Answer

Worsens on exposure to heat

Answer

Can lead to sudden bilateral blindness

Answer

More common in females

Answer

Mostly affects the elderly

Question 9

Which HLA is associated with Reiter syndrome?

Accepted Answer

HLA-B27

Answer

HLA-DQ8

Answer

HLA-DR3

Answer

HLA-DR4

Question 10

What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?

Accepted Answer

Uveitis

Answer

Iridocyclitis

Answer

Scleritis

Answer

Conjunctivitis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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