Rheumatology and Immunology Practice Questions

Q: A 40-year old man presented with acute onset pain and swelling of the left great toe. On X-ray, a punched-out lytic lesion is seen on the phalanx with sclerotic margins and overhanging bony edges. What is the most likely diagnosis?

Gout. ### Explanation The clinical presentation and radiographic findings are classic for **Gouty Arthritis**. **1. Why Gout is Correct:** The patient presents with **Podagra** (acute involvement of the first metatarsophalangeal joint), which is the most common site for gout. The X-ray description is pathognomonic: * **Punched-out lytic lesions:** These represent intraosseous tophi (monosodium urate crystals). * **Martel’s Sign (Overhanging edges):** The sclerotic, "rat-bite" erosions with overhanging bony margins are highly characteristic of chronic tophaceous gout. Unlike other inflammatory arthritides, the joint space in gout is often preserved until late stages. **2. Why Other Options are Incorrect:** * **Rheumatoid Arthritis (RA):** Typically presents with symmetrical involvement of small joints (MCP, PIP). Radiologically, it shows **periarticular osteopenia** and marginal erosions without sclerotic borders or overhanging edges. * **Psoriatic Arthritis:** While it can affect the distal phalanges, it is characterized by the "pencil-in-cup" deformity and periosteal new bone formation, not isolated punched-out lesions with sclerotic margins. * **Reiter’s Syndrome (Reactive Arthritis):** Usually follows a GI or GU infection and presents as an asymmetric oligoarthritis, often involving the heel (Achilles tendonitis) or sacroiliac joints. **3. High-Yield Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Polarized light microscopy showing **needle-shaped, negatively birefringent** crystals (Yellow when parallel to the axis). * **Martel’s Sign:** The radiographic hallmark of gout (overhanging edges). * **Drug of Choice:** NSAIDs are first-line for acute attacks; **Colchicine** is an alternative. **Allopurinol** (Xanthine oxidase inhibitor) is used for chronic management but should *never* be started during an acute attack. * **Dietary triggers:** High purine foods (red meat, seafood) and alcohol.

Q: Which of the following statements is false regarding Familial Mediterranean fever?

Excessive production of TNF-alpha. Explanation: Familial Mediterranean Fever (FMF) is the most common hereditary autoinflammatory syndrome. The correct answer is B because the primary cytokine involved in FMF is Interleukin-1 beta (IL-1β), not TNF-alpha. 1. Why Option B is False: FMF is caused by mutations in the MEFV gene, which encodes the protein pyrin. Pyrin normally regulates the inflammasome complex. Mutated pyrin leads to the uncontrolled activation of the NLRP3 inflammasome, resulting in the excessive production and release of IL-1β. This triggers the characteristic recurrent episodes of fever and serositis (peritonitis, pleuritis, or synovitis). 2. Why Option A is True: FMF is a major cause of AA amyloidosis (secondary amyloidosis) [1]. Chronic, uncontrolled inflammation leads to high levels of Serum Amyloid A (SAA), which deposits in organs, most notably the kidneys, leading to nephrotic syndrome and renal failure [2]. 3. Why Option C is True: FMF follows an autosomal recessive pattern of inheritance, typically seen in populations of Mediterranean descent (Sephardic Jews, Turks, Armenians, and Arabs). 4. Why Option D is True: As mentioned, the MEFV gene mutation directly affects the pyrin protein, impairing its ability to inhibit the inflammatory response. High-Yield Clinical Pearls for NEET-PG: * Drug of Choice: Colchicine is the mainstay of treatment; it prevents acute attacks and, more importantly, prevents the development of AA amyloidosis [1]. * Clinical Presentation: Recurrent, self-limiting episodes of fever (lasting 1–3 days) accompanied by sterile peritonitis (mimicking acute abdomen) or pleuritis. * Erysipeloid Erythema: A pathognomonic skin rash (red, swollen area typically on the lower legs or dorsum of the foot) seen in FMF.

Q: A patient with severe arthritis suddenly becomes unable to move his arms or legs. He is admitted to the neurology floor, but his quadriplegia does not improve with time. If the quadriplegia is due to his arthritis, which of the following types of arthritis does this patient most likely have?

Rheumatoid arthritis. **Explanation:** The correct answer is **Rheumatoid Arthritis (RA)**. The underlying medical concept here is **Atlanto-axial Subluxation (AAS)**. In Rheumatoid Arthritis, chronic inflammation (synovitis) affects the synovial joints of the cervical spine, particularly the **atlanto-axial joint (C1-C2)**. The transverse ligament of the atlas, which holds the odontoid process (dens) of C2 in place, undergoes inflammatory erosion and laxity. This leads to instability and potential subluxation. If the dens displaces posteriorly, it can compress the spinal cord, resulting in sudden-onset **quadriplegia** or even sudden death due to respiratory center compression. **Why other options are incorrect:** * **Ankylosing Spondylitis:** While it involves the spine, it typically causes "bony fusion" (ankylosis) rather than instability. While fractures can occur in a "bamboo spine," spontaneous atlanto-axial subluxation leading to quadriplegia is classic for RA. * **Gouty Arthritis:** This is a metabolic arthropathy primarily affecting peripheral joints (like the 1st MTP joint). It rarely involves the cervical spine or causes cord compression. * **Osteoarthritis:** This is a degenerative condition. While it can cause cervical spondylosis and gradual myelopathy, it does not typically cause the sudden, catastrophic instability seen in RA. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** AAS is diagnosed on lateral cervical X-rays in **flexion**; an **Atlantodental Interval (ADI) >3 mm** in adults is significant. * **Pre-operative Caution:** Patients with RA must undergo cervical spine X-rays before any surgery requiring intubation to avoid fatal cord compression during neck extension. * **Involvement:** RA involves the cervical spine but characteristically **spares** the lumbar spine.

Q: Which of the following crystals may give rise to pseudo-neuropathic arthropathy resembling Charcot's joint?

Calcium pyrophosphate dihydrate. **Explanation:** **Calcium Pyrophosphate Dihydrate (CPPD)** deposition disease is a multifaceted crystal arthropathy. While it most commonly presents as "Pseudogout," it can manifest in several clinical patterns. One specific, severe form is **Pseudo-neuropathic arthropathy**. In this variant, the rapid and extensive destruction of the joint (most commonly the knee or hip) mimics the clinical and radiological appearance of a **Charcot’s Joint**. Unlike true Charcot’s joint, which is secondary to loss of sensation (e.g., Diabetes, Syphilis), CPPD-induced arthropathy occurs in the presence of intact neurological function. **Analysis of Incorrect Options:** * **A. Monosodium Urate (MSU):** These crystals cause Gout. While chronic tophaceous gout can lead to joint erosion and "punched-out" lesions, it does not typically mimic the rapid, disorganized joint destruction seen in neuropathic arthropathy. * **B. Hydroxyapatite:** These crystals are associated with calcific tendonitis and "Milwaukee Shoulder." While destructive, the term "pseudo-neuropathic" is classically reserved for CPPD. * **C. Calcium Oxalate:** These crystals are primarily seen in patients with primary oxalosis or those on long-term hemodialysis; they do not present with a Charcot-like joint destruction. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Hallmark:** The presence of **Chondrocalcinosis** (linear calcification of articular cartilage or fibrocartilage, like the meniscus). * **Crystal Morphology:** CPPD crystals are **weakly positively birefringent** and **rhomboid-shaped** under polarized microscopy. * **Metabolic Associations:** Always screen for "The 3 H's": **H**yperparathyroidism, **H**emochromatosis, and **H**ypomagnesemia. * **Common Site:** The **Knee** is the most common joint involved in CPPD.

Q: Takayasu's arteritis with pulmonary artery involvement is designated as which type?

Type IV. **Explanation:** Takayasu’s Arteritis (Pulseless Disease) is a chronic inflammatory large-vessel vasculitis that primarily affects the aorta and its main branches [1]. The classification of Takayasu’s arteritis is based on the anatomical distribution of the lesions as defined by the **Numano Classification (1996)**: * **Type IV (Correct Answer):** This type specifically involves the **Pulmonary Artery**. It can occur in isolation or in combination with any of the other types (e.g., Type IV+). Pulmonary involvement can lead to pulmonary hypertension and is a critical prognostic factor. **Analysis of Incorrect Options:** * **Type I:** Involves only the branches of the **Aortic Arch** (e.g., carotid, subclavian arteries). * **Type II:** Involves the **Ascending Aorta, Aortic Arch, and its branches** (Type IIa) or extends to include the **Thoracic Descending Aorta** (Type IIb). * **Type III:** Involves the **Thoracic Descending Aorta, Abdominal Aorta, and/or Renal Arteries**. The aortic arch is spared. * **Type V:** A generalized form combining features of Type IIb and Type III (involvement of the entire aorta and its branches). **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in young females (<40 years) of Asian descent. * **Clinical Feature:** Discrepancy in blood pressure between arms and absent/feeble peripheral pulses. * **Diagnosis:** Magnetic Resonance Angiography (MRA) or CT Angiography is the gold standard for visualizing vessel wall thickening and narrowing [1]. * **Pathology:** Characterized by "skip lesions" and granulomatous inflammation of the adventitia and media. * **Treatment:** Glucocorticoids are the first-line treatment.

Q: A 44-year-old businessman presents with a markedly inflamed and painful right great toe. He reports increasing pain in his right foot during a recent plane trip. Physical examination reveals swelling and erythema of the right great toe, along with small nodules on his external ears. Aspiration of the metatarsophalangeal joint of the affected toe shows needle-shaped, negatively birefringent crystals. Which of the following agents would provide the most immediate relief for this patient?

Colchicine. ### Explanation **Correct Option: C. Colchicine** This patient presents with a classic case of **Acute Gouty Arthritis** (Podagra), triggered by dehydration during a flight [3]. The diagnosis is confirmed by the presence of **tophi** (nodules on the ear) [2] and the pathognomonic finding of **needle-shaped, negatively birefringent monosodium urate (MSU) crystals** under polarized light microscopy. **Why Colchicine is correct:** In an acute gouty attack, the goal is to reduce inflammation rapidly. **Colchicine** works by inhibiting microtubule polymerization (binding to tubulin), which prevents leukocyte migration and phagocytosis of urate crystals, thereby providing immediate symptomatic relief. Other first-line agents include NSAIDs (e.g., Indomethacin) and Corticosteroids. **Why other options are incorrect:** * **A. Allopurinol:** This is a Xanthine Oxidase inhibitor used for **chronic** management (urate-lowering therapy) [1]. Starting it during an acute attack can worsen the inflammation by causing rapid fluctuations in serum urate levels, leading to further crystal mobilization [1]. * **B. Aspirin:** Low-dose aspirin is contraindicated in gout because it inhibits the renal excretion of uric acid (via OAT transporters), potentially worsening hyperuricemia. * **D. Probenecid:** This is a uricosuric agent used for chronic gout in patients with underexcretion of uric acid [1]. Like Allopurinol, it has no role in managing acute inflammation. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard Diagnosis:** Polarized light microscopy showing **negative birefringence** (crystals appear yellow when parallel to the slow axis). * **Radiology:** Look for

Q: A 23-year-old man presents with gradual and progressive dyspnea. He has a long history of back pain with prolonged morning stiffness and a past episode of iritis. Physical examination reveals reduced lumbar spine mobility with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissues. Pelvic X-rays show sacroiliac joint erosions and sclerosis. What is the most likely pulmonary complication associated with this condition?

Upper lobe fibrosis. **Explanation:** The clinical presentation of chronic back pain with morning stiffness, history of iritis, reduced lumbar mobility, and sacroiliac joint sclerosis in a young male is diagnostic of **Ankylosing Spondylitis (AS)** [1]. **1. Why Option A is correct:** While the most common pulmonary finding in AS is actually a **restrictive lung pattern** due to chest wall restriction (costovertebral joint involvement), the most characteristic and "classic" parenchymal complication is **apical (upper lobe) fibrocystic disease**. This typically manifests as bilateral, symmetric upper lobe fibrosis and cavitation, which can mimic tuberculosis. These cavities may become colonized by *Aspergillus*, leading to mycetoma formation. **2. Why the other options are incorrect:** * **B. Airflow obstruction:** AS primarily causes restrictive lung disease, not obstructive. Airflow is usually preserved unless the patient has a co-existing condition like COPD. * **C. Chronic pulmonary embolism:** There is no direct association between AS and chronic PE. * **D. Pleural effusions:** While pleuritis can rarely occur in AS, it is much more characteristic of Systemic Lupus Erythematosus (SLE) or Rheumatoid Arthritis (RA). **Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated with AS (>90% of cases) [1]. * **Schober’s Test:** Used to assess restricted lumbar flexion. * **Bamboo Spine:** Late-stage radiographic finding due to syndesmophyte formation and ligamentous calcification [1]. * **Extra-articular manifestations:** Acute anterior uveitis (most common), Aortitis/Aortic regurgitation, and Apical lung fibrosis [1]. * **Treatment:** NSAIDs are first-line; TNF-alpha inhibitors (e.g., Etanercept, Infliximab) are used for refractory cases.

Q: The 'Pathergy Test' is specific for which of the following conditions?

Behcet's syndrome. **Explanation:** The **Pathergy Test** is a diagnostic tool used to identify cutaneous hypersensitivity to minor trauma. It is a hallmark clinical feature and a highly specific diagnostic criterion for **Behcet’s Syndrome**. **1. Why Behcet’s Syndrome is correct:** Behcet’s is a multi-system, chronic relapsing vasculitis. The pathergy phenomenon occurs due to an exaggerated inflammatory response by neutrophils to a local insult. * **Procedure:** A sterile 20-gauge needle is pricked into the skin (usually the forearm). * **Positive Result:** Formation of a sterile erythematous papule or pustule (>2mm) at the site of the prick within 24–48 hours. * **Significance:** While highly specific for Behcet's, the test's sensitivity varies geographically (highest in Silk Road populations). **2. Why other options are incorrect:** * **Caplan’s Syndrome:** This is the combination of Rheumatoid Arthritis (RA) and Coal Workers' Pneumoconiosis, characterized by intrapulmonary nodules. * **Sjogren’s Syndrome:** An autoimmune destruction of exocrine glands (lacrimal/salivary). Diagnosis relies on the Schirmer’s test, anti-Ro/SSA, and anti-La/SSB antibodies [1]. * **Felty’s Syndrome:** A triad of Rheumatoid Arthritis, Splenomegaly, and Neutropenia. It does not involve skin hypersensitivity. **Clinical Pearls for NEET-PG:** * **Behcet’s Triad:** Recurrent oral ulcers (most common), genital ulcers (most specific), and uveitis. * **HLA Association:** Strongly linked with **HLA-B51**. * **Other Pathergy-positive conditions:** Pyoderma Gangrenosum and Sweet’s Syndrome (Neutrophilic dermatosis) can also show pathergy, but in the context of systemic vasculitis questions, Behcet’s is the primary answer. * **Treatment:** Colchicine is often the first-line agent for mucocutaneous symptoms. [Note: Provided references discussed Sjögren's antibodies but did not contain specific text for Behcet's Syndrome pathergy dynamics].

Question 1

A 65-year-old man develops the onset of severe right knee pain over 24 hours. The knee is red, swollen, and tender. The patient does not have fever or systemic symptoms; he has never had severe joint pain before. Plain film of the knee shows linear calcification of the articular cartilage without destructive change. Definitive diagnosis is best made by which of the following?

Accepted Answer

Arthrocentesis and identification of positively birefringent rhomboid crystals

Answer

Serum uric acid

Answer

Serum calcium

Answer

Rheumatoid factor

Question 2

A 40-year old man presented with acute onset pain and swelling of the left great toe. On X-ray, a punched-out lytic lesion is seen on the phalanx with sclerotic margins and overhanging bony edges. What is the most likely diagnosis?

Accepted Answer

Gout

Answer

Rheumatoid arthritis

Answer

Psoriatic arthritis

Answer

Reiter's syndrome

Question 3

Which of the following statements is false regarding Familial Mediterranean fever?

Accepted Answer

Excessive production of TNF-alpha

Answer

Form of hereditary amyloidosis

Answer

Autosomal recessive inheritance

Answer

Mutation affecting pyrin protein

Question 4

A patient with severe arthritis suddenly becomes unable to move his arms or legs. He is admitted to the neurology floor, but his quadriplegia does not improve with time. If the quadriplegia is due to his arthritis, which of the following types of arthritis does this patient most likely have?

Accepted Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Answer

Gouty arthritis

Answer

Osteoarthritis

Question 5

Which of the following crystals may give rise to pseudo-neuropathic arthropathy resembling Charcot's joint?

Accepted Answer

Calcium pyrophosphate dihydrate

Answer

Monosodium urate

Answer

Hydroxyapatite

Answer

Calcium oxalate

Question 6

Takayasu's arteritis with pulmonary artery involvement is designated as which type?

Accepted Answer

Type IV

Answer

Type I

Answer

Type II

Answer

Type III

Question 7

A 44-year-old businessman presents with a markedly inflamed and painful right great toe. He reports increasing pain in his right foot during a recent plane trip. Physical examination reveals swelling and erythema of the right great toe, along with small nodules on his external ears. Aspiration of the metatarsophalangeal joint of the affected toe shows needle-shaped, negatively birefringent crystals. Which of the following agents would provide the most immediate relief for this patient?

Accepted Answer

Colchicine

Answer

Allopurinol

Answer

Aspirin

Answer

Probenecid

Question 8

A 23-year-old man presents with gradual and progressive dyspnea. He has a long history of back pain with prolonged morning stiffness and a past episode of iritis. Physical examination reveals reduced lumbar spine mobility with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissues. Pelvic X-rays show sacroiliac joint erosions and sclerosis. What is the most likely pulmonary complication associated with this condition?

Accepted Answer

Upper lobe fibrosis

Answer

Airflow obstruction

Answer

Chronic pulmonary embolism

Answer

Pleural effusions

Question 9

The 'Pathergy Test' is specific for which of the following conditions?

Accepted Answer

Behcet's syndrome

Answer

Caplan's syndrome

Answer

Sjogren's syndrome

Answer

Felty's syndrome

Question 10

A patient presents with musculoskeletal complaints. What feature is suggestive of a non-articular origin of pain?

Accepted Answer

Pain on active movement but not on passive movement

Answer

Pain or decreased range of motion on both active and passive movement

Answer

Swelling

Answer

Crepitation

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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