Rheumatology and Immunology — MCQs

Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs

Question 881: Arthritis involving DIP, PIP, 1st carpometacarpal with sparing of MCP and wrist joints is typical of ?

A. Osteoarthritis (Correct Answer)
B. Rheumatoid arthritis
C. Ankylosing spondylitis
D. Psoriatic arthritis

Explanation: ***Osteoarthritis*** - **Osteoarthritis** characteristically affects the **DIP (Heberden's nodes)**, **PIP (Bouchard's nodes)**, and the **first carpometacarpal joint** at the base of the thumb [1]. - It typically spares the **MCP and wrist joints**, which helps differentiate it from inflammatory arthropathies like rheumatoid arthritis [1], [2]. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **MCP and wrist joints**, sparing the DIP joints [2]. - It presents with **symmetrical polyarthritis** and often includes systemic symptoms [2]. *Ankylosing spondylitis* - **Ankylosing spondylitis** primarily affects the **axial skeleton**, particularly the sacroiliac joints and spine. - While peripheral joint involvement can occur, it's typically in larger joints and not the characteristic DIP/PIP pattern of this case. *Psoriatic arthritis* - **Psoriatic arthritis** can affect the **DIP joints** and can present with patterns similar to osteoarthritis or rheumatoid arthritis [3]. - However, it's strongly associated with **psoriasis** (skin and nail changes) and can involve various other patterns, including **dactylitis** (sausage digits) and enthesitis, which makes it less typical for the described sparing pattern alone [3].

Question 882: What is the most common variant of Takayasu Disease in India?

A. Type III
B. Type V (Correct Answer)
C. Type IV
D. Type I

Explanation: ***Type V*** - **Type V Takayasu arteritis** involves both the **aortic arch and its branches** (similar to Type I or II) AND the **abdominal aorta** and/or **renal arteries** (similar to Type III or IV) [1]. - This extensive involvement is the **most common presentation** of Takayasu arteritis in India, characterized by widespread vasculopathy affecting multiple arterial segments. *Type I* - **Type I Takayasu arteritis** primarily affects the **aortic arch** and its main branches, such as the subclavian, carotid, and vertebral arteries [1]. - While present in India, it is **less common** than Type V, which also includes abdominal aortic involvement. *Type III* - **Type III Takayasu arteritis** involves the **thoracic descending aorta, abdominal aorta**, and/or **renal arteries**, in addition to the **aortic arch branches**. - Although it includes abdominal involvement, it does not encompass the full range of involvement seen in the most prevalent Indian variant, Type V. *Type IV* - **Type IV Takayasu arteritis** is characterized by involvement of the **abdominal aorta** and/or **renal arteries** [1]. - This type is less common as a sole presentation in India; typically, renal artery involvement is part of a more generalized arterial inflammation, as seen in Type V.

Question 883: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?

A. Acute interstitial nephritis
B. Poststreptococcal glomerulonephritis
C. Lupus nephritis (Correct Answer)
D. IgA nephropathy

Explanation: ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.

Question 884: A patient presents with a history of arthritis affecting the 1st metacarpophalangeal (MCP) joint, as well as other proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, while sparing the wrist and ankle joints. What is the most likely diagnosis?

A. Osteoarthritis (Correct Answer)
B. Rheumatoid arthritis
C. Psoriatic arthritis
D. Gout

Explanation: ***Osteoarthritis*** - **Osteoarthritis** typically affects the **1st carpometacarpal (CMC)* joint (of which the 1st MCP is a part), **proximal interphalangeal (PIP)**, and **distal interphalangeal (DIP)** joints, consistent with the patient's presentation [1]. - It classically **spares the wrist and ankle joints** in its early stages, supporting this diagnosis. *Rheumatoid arthritis* - **Rheumatoid arthritis** characteristically affects the **metacarpophalangeal (MCP)** and **proximal interphalangeal (PIP)** joints symmetrically, but typically **spares the distal interphalangeal (DIP) joints** [1]. - It frequently involves the **wrist and ankle joints**, which are noted as spared in this case [1]. *Psoriatic arthritis* - **Psoriatic arthritis** can affect DIP joints and may present with different patterns, but a classic presentation often includes **dactylitis** (sausage digits) or nail changes, which are not mentioned [1]. - While it can affect the hand joints, the specific pattern described, including the sparing of the wrist and ankle, is not its most typical presentation. *Gout* - **Gout** is characterized by acute, severe pain, typically in a single joint, with the **first metatarsophalangeal (MTP) joint** (of the big toe) being most commonly affected, known as podagra. - While gout can affect other joints, its episodic nature and acute inflammatory presentation differ from the chronic, progressive pattern suggested by the question.

Question 885: Which of the following is the MOST specific statement regarding Polyarteritis Nodosa (PAN)?

A. Patients with PAN may exhibit hypergammaglobulinemia.
B. Approximately 30% of patients with Polyarteritis Nodosa (PAN) are HBsAg positive.
C. ANCA is typically negative in PAN. (Correct Answer)
D. Microscopy shows fibrinoid necrosis in medium-sized arteries

Explanation: ***30% of people have HbsAg positive*** - Hepatitis B virus infection is associated with **polyarteritis nodosa (PAN)**, with **30%** of patients having a positive **HbsAg**. - The presence of **HbsAg** indicates active Hepatitis B, which can lead to vasculitis seen in PAN. *Microscopy shows fibrinoid necrosis in large arteries* - While fibrinoid necrosis is present in vasculitides [1], it is more characteristic of **granulomatosis with polyangiitis** (Wegener's) rather than PAN. - PAN typically shows **intranuclear inclusions** and necrotizing vasculitis without predominant fibrinoid necrosis. *Patient have hypogammaglobulinemia* - Patients with PAN do not typically present with **hypogammaglobulinemia**; rather, they may have normal immunoglobulin levels. - Hypogammaglobulinemia is more commonly associated with other types of vasculitis, such as **SLE** or **chronic infections**. *ANCA is positive* - Perinuclear anti-neutrophil cytoplasmic antibodies (**ANCA**) are usually associated with **granulomatosis and eosinophilic granulomatosis** rather than PAN. - PAN is **ANCA-negative** and is characterized by alternate antibodies, particularly if associated with Hepatitis B.

Question 886: Which of the following is a characteristic feature of seropositive rheumatoid arthritis?

A. Generalized joint pain and swelling
B. Morning stiffness lasting more than 30 minutes
C. Presence of rheumatoid factor (RF) (Correct Answer)
D. Joint deformities

Explanation: Presence of rheumatoid factor (RF) - **Seropositive rheumatoid arthritis** is specifically defined by the presence of **rheumatoid factor (RF)** or anti-citrullinated protein antibodies (anti-CCP), indicating a particular immunological subtype of the disease [1]. - The detection of **RF**, an autoantibody, is a key diagnostic marker that helps differentiate seropositive RA from seronegative forms and other inflammatory arthritides [1]. Joint deformities - Joint deformities, such as **ulnar deviation** or **boutonnière and swan neck deformities**, are a common *consequence* of chronic, uncontrolled rheumatoid arthritis [2]. - While characteristic of advanced disease, deformities are not a *defining feature* for the initial classification of **seropositive RA**, which is based on serological markers. Morning stiffness lasting more than 30 minutes - **Morning stiffness** that persists for more than 30 minutes is a classic *symptom* of inflammatory arthritis, including both seropositive and seronegative RA [3]. - Although it is an important diagnostic criterion for RA in general, it is not specific to the **seropositive subtype** because it can be present in other inflammatory arthropathies as well [3]. Generalized joint pain and swelling - **Generalized joint pain and swelling**, typically in a symmetrical pattern affecting small joints, are core *symptoms* of rheumatoid arthritis and indicate active inflammation [3]. - These symptoms are common in all forms of RA, including both seropositive and seronegative, and thus do not specifically characterize the **seropositive subtype**.

Question 887: Sausage finger appearance is associated with which of the following conditions?

A. Rickets
B. Hyperthyroidism
C. Addison's disease
D. Psoriatic arthritis (Correct Answer)

Explanation: ***Psoriatic arthritis*** - **Dactylitis**, or "sausage finger," is a characteristic inflammatory finding in psoriatic arthritis, resulting from inflammation of the **entire digit** [1]. - This condition involves inflammation of tendons, joints, and soft tissues which leads to diffuse swelling of fingers or toes [1]. *Rickets* - Rickets is a bone-softening disease in children caused by **vitamin D deficiency**, leading to bone deformities like bowed legs or widened wrists. - It does not present with inflammatory dactylitis or "sausage digits." *Hyperthyroidism* - Hyperthyroidism is a condition of excessive thyroid hormone production, which can cause symptoms like **tremors**, **tachycardia**, and **weight loss** [2]. - It is not associated with dactylitis or changes in finger morphology. *Addison's disease* - Addison's disease results from **adrenal insufficiency**, leading to symptoms like **fatigue**, **skin hyperpigmentation**, and hypotension. - There is no clinical association between Addison's disease and "sausage finger" appearance.

Question 888: Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

A. ANCA (Correct Answer)
B. RA factor
C. Hbsag
D. MIF

Explanation: ### ANCA - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points towards a small-vessel vasculitis, for which **ANCA (anti-neutrophil cytoplasmic antibodies)** testing is crucial [1]. - ANCA is highly specific for conditions like **Granulomatosis with Polyangiitis (GPA)** and **Microscopic Polyangiitis (MPA)** [1]. ### RA factor - **Rheumatoid factor (RF)** is primarily associated with **rheumatoid arthritis**, which typically presents with symmetrical polyarthritis, not the constellation of symptoms described. - While RF can be positive in some vasculitides, it is not the most specific initial test for the given clinical presentation. ### Hbsag - **Hepatitis B surface antigen (HbsAg)** typically screens for **Hepatitis B infection**, which can cause **polyarteritis nodosa (PAN)**, a medium-vessel vasculitis. - However, the patient's symptoms (cutaneous vasculitis, glomerulonephritis) are more characteristic of **small-vessel vasculitis**, making ANCA a more direct investigation [1]. ### MIF - **MIF (Macrophage Migration Inhibitory Factor)** is a cytokine involved in inflammation, but it is not a routine diagnostic marker for vasculitis. - It is not used as a primary investigation to diagnose specific autoimmune or inflammatory conditions like vasculitis.

Question 889: In long standing rheumatoid arthritis, which condition is commonly observed?

A. Milk alkali syndrome
B. Nephrolithiasis
C. Paradoxical aciduria
D. Secondary amyloidosis (Correct Answer)

Explanation: ***Secondary amyloidosis*** - Chronic inflammation in **rheumatoid arthritis** can lead to the production and deposition of **amyloid A protein**, which is the hallmark of secondary (AA) amyloidosis [1]. - **Secondary amyloidosis** can affect various organs, including the kidneys, heart, and gastrointestinal tract, leading to organ dysfunction [1]. *Milk alkali syndrome* - This condition is caused by excessive intake of **calcium** and absorbable alkali, resulting in **hypercalcemia** and **metabolic alkalosis**. - It is not directly associated with the chronic inflammatory process of rheumatoid arthritis. *Nephrolithiasis* - **Kidney stones** (nephrolithiasis) are often associated with genetic predispositions, dietary factors, and certain metabolic conditions like **hypercalciuria** or **hyperoxaluria**. - There is no direct causal link between **rheumatoid arthritis** and an increased risk of common types of kidney stones. *Paradoxical aciduria* - This condition is characterized by the excretion of acidic urine in the presence of **metabolic alkalosis**, typically due to **volume depletion** and **hypokalemia**. - While it reflects a disturbance in acid-base balance and renal function, it is not a direct or commonly observed complication of long-standing rheumatoid arthritis itself.

Question 890: All of the following are true about Gout, except which of the following?

A. Can be precipitated by pyrazinamide
B. Birefringent crystals are present in the joint
C. Occurs due to accumulation of urate crystals in joint
D. Occurs more in females (Correct Answer)

Explanation: ***Occurs more in females*** - **Gout** is more prevalent in **males** than in females, especially before menopause, due to hormonal differences and lifestyle factors. - After menopause, the incidence in females increases but generally remains lower than in males. *Occurs due to accumulation of urate crystals in joint* - **Gout** is precisely characterized by the **deposition of monosodium urate crystals** in joints and surrounding tissues, leading to inflammation [1], [2]. - This accumulation is a direct consequence of **hyperuricemia**, either from overproduction or underexcretion of uric acid [2], [3]. *Can be precipitated by pyrazinamide* - **Pyrazinamide** is an anti-tuberculosis drug known to **inhibit uric acid excretion** by the kidneys. - This leads to **hyperuricemia**, thereby increasing the risk of acute gout attacks. *Birefringent crystals are present in the joint* - Microscopic examination of **synovial fluid** from a gouty joint reveals **needle-shaped, negatively birefringent crystals** of monosodium urate [1], [4]. - This finding is a definitive diagnostic criterion for **gout**.

Practice by Chapter

Rheumatoid Arthritis

Practice Questions

Spondyloarthropathies

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Systemic Lupus Erythematosus

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Vasculitis Syndromes

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Scleroderma and Related Disorders

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Inflammatory Myopathies

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Crystal Arthropathies

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Osteoarthritis

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Primary Immunodeficiency Disorders

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Autoinflammatory Syndromes

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Sjögren's Syndrome

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Antiphospholipid Syndrome

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