Rheumatology and Immunology Practice Questions

Q: All of the following are true about temporal arteritis except?

Low ESR. Explanation: Temporal Arteritis (Giant Cell Arteritis) is a large-vessel vasculitis that primarily affects the extracranial branches of the carotid artery [1]. Why "Low ESR" is the correct answer: In Temporal Arteritis, the Erythrocyte Sedimentation Rate (ESR) is characteristically markedly elevated, often exceeding 100 mm/hr. A low or normal ESR is extremely rare in active disease [1]. C-reactive protein (CRP) is also typically elevated. Analysis of other options: * Polymyalgia Rheumatica (PMR): Approximately 40–50% of patients with Temporal Arteritis also have PMR, characterized by proximal muscle pain and stiffness (shoulders and hips) [1]. * Anemia: Chronic inflammation in vasculitis leads to Anemia of Chronic Disease (normocytic, normochromic), which is a common systemic finding in these patients [1]. * Sudden Blindness: This is the most dreaded complication. It occurs due to Anterior Ischemic Optic Neuropathy (AION) caused by occlusion of the posterior ciliary arteries. It is a medical emergency requiring immediate high-dose corticosteroids [1]. High-Yield Clinical Pearls for NEET-PG: * Demographics: Almost exclusively occurs in patients >50 years of age. * Gold Standard Diagnosis: Temporal artery biopsy (look for "skip lesions"; hence a long segment must be biopsied) [1]. * Histopathology: Granulomatous inflammation with multinucleated giant cells and fragmentation of the internal elastic lamina [1]. * Treatment: Do not wait for biopsy results; start High-dose Glucocorticoids immediately if clinical suspicion is high to prevent permanent vision loss [1].

Q: Tietze's syndrome usually develops at the costal cartilage of which ribs?

Second to fifth ribs. **Explanation:** **Tietze’s Syndrome** is a benign, inflammatory condition characterized by painful swelling of the costochondral or costosternal joints. It is often confused with costochondritis, but the distinguishing feature of Tietze’s is the presence of **palpable localized swelling**. 1. **Why Option B is Correct:** The syndrome most commonly affects the **second to fifth costal cartilages**. The second costal cartilage is the most frequent site of involvement. The inflammation leads to localized edema and tenderness at these specific junctions where the ribs meet the sternum. 2. **Why Other Options are Incorrect:** * **Option A:** While the first rib can occasionally be involved, it is rarely the primary or sole site compared to the 2nd–5th range. * **Option C:** The lower ribs (6th–8th) are less frequently involved because they lack the same degree of mechanical stress and mobility seen at the upper costosternal junctions. * **Option D:** It is rare for all seven true ribs to be involved simultaneously; the condition is typically localized to one or two levels. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis:** It is a crucial differential for **acute chest pain**. Unlike a myocardial infarction, the pain in Tietze’s syndrome is reproducible by palpation (localized tenderness). * **Tietze’s vs. Costochondritis:** Tietze’s syndrome presents with **swelling**, whereas costochondritis presents with pain **without** swelling. * **Demographics:** It usually affects young adults (under 40 years) and is often self-limiting. * **Radiology:** X-rays are usually normal, but an MRI or Ultrasound may show thickening of the affected cartilage.

Q: Diffuse cutaneous systemic sclerosis is characterized by which of the following?

Early pulmonary fibrosis. **Explanation:** Systemic Sclerosis (SSc) is divided into two main subsets: **Diffuse Cutaneous (dcSSc)** and **Limited Cutaneous (lcSSc)**. The distinction is based on the extent of skin involvement and the timing of internal organ complications. [1] **Why Option A is Correct:** In **Diffuse Cutaneous SSc**, skin thickening involves the proximal limbs and trunk. Crucially, it is characterized by the **early onset of internal organ involvement**, most notably **Interstitial Lung Disease (Pulmonary Fibrosis)** and scleroderma renal crisis. [2] Pulmonary fibrosis often develops within the first 5 years of disease onset and is a leading cause of mortality in these patients. [3] **Why Other Options are Incorrect:** * **B. Raynaud’s Phenomenon:** While present in both types, it typically precedes skin changes by years in *limited* SSc. In *diffuse* SSc, Raynaud’s often occurs concurrently with or shortly before skin thickening. * **C. Calcinosis Cutis:** This is a classic feature of the **CREST syndrome**, which is the hallmark of **Limited Cutaneous SSc**. While it can occur in dcSSc, it is far more characteristic of the limited subtype. * **D. Better long-term prognosis:** This is incorrect. dcSSc has a **worse prognosis** compared to lcSSc due to rapid skin progression and early, severe visceral involvement (lung, heart, and kidney). **NEET-PG High-Yield Pearls:** * **Antibody Association:** dcSSc is linked to **Anti-Scl-70 (Anti-topoisomerase I)**; lcSSc is linked to **Anti-centromere antibodies**. * **Pulmonary Hypertension:** More commonly an isolated, late complication in *Limited* SSc. * **Renal Crisis:** Most common in *Diffuse* SSc; treated with **ACE inhibitors** (even if creatinine is elevated).

Q: This type of lesion is most commonly seen in which disease?

Rheumatoid Arthritis (RA). ***Rheumatoid Arthritis (RA)*** - **Rheumatoid nodules** are pathognomonic subcutaneous lesions found in approximately 20-30% of RA patients, typically over **pressure points** like elbows and knuckles. - These firm, non-tender nodules consist of a **central necrotic core** surrounded by **epithelioid cells** and are strongly associated with **positive rheumatoid factor** and severe disease. *Systemic Lupus Erythematosus (SLE)* - Characteristic skin lesions include the **malar rash** (butterfly rash) and **discoid lesions**, not subcutaneous nodules. - **Photosensitive rashes** and **oral ulcers** are more typical dermatological manifestations of SLE. *Gout* - **Tophi** are urate crystal deposits that can occur in chronic gout, but they are typically **chalky white** and located around joints, ears, or tendons. - Tophi develop after years of **hyperuricemia** and are composed of **monosodium urate crystals**, unlike the inflammatory nodules in RA. *Marfan syndrome* - This connective tissue disorder primarily affects the **cardiovascular**, **skeletal**, and **ocular systems** without characteristic skin nodules. - Skin manifestations include **striae distensae** and **hyperextensible skin**, but not subcutaneous nodular lesions.

Q: Groton's sign is seen in which of the following conditions?

Dermatomyositis. **Explanation:** **Gottron’s sign** (often referred to as Gottron papules) is a pathognomonic cutaneous manifestation of **Dermatomyositis** [1]. It consists of symmetric, erythematous to violaceous, somewhat scaly patches or papules found over the dorsal aspects of the interphalangeal (IP) and metacarpophalangeal (MCP) joints [1]. The underlying medical concept involves an autoimmune-mediated microvascular injury that manifests as these characteristic skin lesions alongside proximal muscle weakness [2]. **Analysis of Options:** * **Dermatomyositis (Correct):** Gottron’s sign and the Heliotrope rash (periorbital violaceous discoloration) are the hallmark dermatological findings [1]. * **Systemic Lupus Erythematosus (SLE):** While SLE presents with a malar (butterfly) rash, it typically **spares the IP/MCP joints** (interarticular sparing), unlike Dermatomyositis which specifically involves them. * **Scleroderma:** Characterized by skin thickening (sclerodactyly), Raynaud’s phenomenon, and telangiectasia, but not Gottron’s papules. * **MCTD:** This is an overlap syndrome (SLE, Scleroderma, and Polymyositis features) associated with **anti-U1 RNP antibodies**. While it can have features of myositis, Gottron’s sign is specifically diagnostic for Dermatomyositis. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic triad for Dermatomyositis:** Gottron’s papules, Heliotrope rash, and Shawl sign (erythema over shoulders/neck) [1]. * **Mechanic’s Hands:** Hyperkeratotic, fissured skin on the lateral fingers; highly associated with **Anti-Jo-1 antibodies** (Antisynthetase syndrome) [2]. * **Malignancy Risk:** Dermatomyositis in adults is associated with an increased risk of internal malignancies (Ovarian, Lung, Gastric); age-appropriate cancer screening is mandatory [1]. * **Muscle Enzymes:** Elevated Creatine Kinase (CK) and Aldolase are key laboratory findings [1].

Q: A 33-year-old woman has experienced episodes of fatigue, pleural effusion, pericardial effusion, carpal tunnel syndrome, and macrocytic anemia. What is the best test for diagnosis?

Assay for thyroid hormones. ### Explanation The clinical presentation of fatigue, serositis (pleural and pericardial effusions), carpal tunnel syndrome, and macrocytic anemia in a young woman is a classic "clinical trap" designed to mimic Systemic Lupus Erythematosus (SLE). However, these features are collectively highly characteristic of **Hypothyroidism** [1]. **1. Why "Assay for Thyroid Hormones" is correct:** * **Serositis:** Hypothyroidism causes increased capillary permeability and decreased lymphatic drainage, leading to protein-rich effusions (pleural/pericardial). * **Carpal Tunnel Syndrome:** Deposition of mucopolysaccharides (glycosaminoglycans) in the flexor retinaculum causes median nerve compression [1]. * **Macrocytic Anemia:** While hypothyroidism can cause normocytic anemia, it is a well-known cause of non-megaloblastic macrocytosis. Additionally, it is frequently associated with Pernicious Anemia (Autoimmune Polyendocrine Syndrome). * **Fatigue:** A hallmark constitutional symptom of low metabolic states [1]. **2. Why the other options are incorrect:** * **Options A, B, and C (Antiphospholipid, Anti-Smith, ANA):** These are markers for SLE. While SLE causes serositis and fatigue, it typically presents with inflammatory markers, cytopenias (usually microcytic or hemolytic anemia), and rashes. It does **not** typically cause carpal tunnel syndrome or non-hemolytic macrocytic anemia. **Clinical Pearls for NEET-PG:** * **The "Great Mimicker":** Hypothyroidism should be a top differential for any patient presenting with unexplained serositis and weight gain. * **Anemia Patterns:** Hypothyroidism is the most common endocrine cause of **macrocytosis**. * **Reversible CTS:** Carpal tunnel syndrome in hypothyroidism is often reversible with thyroxine replacement. * **Woltman Sign:** Look for "delayed relaxation of deep tendon reflexes" in the clinical stem to confirm a thyroid etiology [1].

Q: Which of the following is a feature of osteoarthritis?

Heberden node. **Explanation:** **Osteoarthritis (OA)** is a degenerative joint disease characterized by the progressive loss of articular cartilage and the formation of new bone (osteophytes) at the joint margins [1]. 1. **Heberden Nodes (Correct Answer):** These are palpable bony enlargements (osteophytes) located at the **Distal Interphalangeal (DIP) joints**. They are a hallmark clinical feature of nodal OA [1]. Similar enlargements at the **Proximal Interphalangeal (PIP) joints** are known as **Bouchard nodes** [1]. 2. **Increased ESR (Incorrect):** OA is primarily a non-inflammatory, degenerative condition [1]. Therefore, systemic inflammatory markers like Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) are typically **normal**. An elevated ESR suggests an inflammatory arthritis like Rheumatoid Arthritis (RA) or systemic lupus erythematosus. 3. **Onycholysis (Incorrect):** This refers to the painless separation of the nail from the nail bed. It is a classic dermatological feature of **Psoriatic Arthritis**, not OA. 4. **Z-deformity (Incorrect):** This is a characteristic deformity of the hand seen in **Rheumatoid Arthritis**, consisting of radial deviation at the wrist and ulnar deviation of the digits. **High-Yield Clinical Pearls for NEET-PG:** * **Joint Involvement:** OA characteristically involves the DIP, PIP, and the 1st Carpometacarpal (CMC) joint (squaring of the wrist) [1]. It **spares** the Metacarpophalangeal (MCP) joints, which are typically involved in RA. * **Radiological Hallmarks:** Joint space narrowing (asymmetrical), subchondral sclerosis, subchondral cysts, and osteophytes [1]. * **Pain Pattern:** Pain worsens with activity and is relieved by rest (unlike RA, where stiffness improves with activity) [1]. * **Synovial Fluid:** Non-inflammatory (WBC count <2000 cells/mm³).

Q: In which of the following conditions is the proximal interphalangeal joint involved while the distal interphalangeal joint is spared?

Rheumatoid arthritis. **Explanation:** **Rheumatoid Arthritis (RA)** is a chronic inflammatory systemic disease that primarily targets the **synovium**. The hallmark of RA in the hands is the involvement of the **Proximal Interphalangeal (PIP)** and **Metacarpophalangeal (MCP)** joints, while characteristically **sparing the Distal Interphalangeal (DIP) joints**. This sparing occurs because the DIP joints have minimal synovial tissue compared to the more proximal joints. **Analysis of Options:** * **Osteoarthritis (OA):** Typically involves the **DIP joints** (forming Heberden’s nodes) and the PIP joints (forming Bouchard’s nodes). The involvement of the DIP joint is a classic differentiating feature from RA. * **Psoriatic Arthritis:** This seronegative spondyloarthropathy is notorious for involving the **DIP joints**. It often presents with "dactylitis" (sausage digits) and nail pitting. * **Ankylosing Spondylitis:** Primarily affects the axial skeleton (sacroiliac joints and spine). While it can involve peripheral joints, it usually affects large girdle joints (hips/shoulders) rather than the small joints of the hand in the pattern described. **High-Yield Clinical Pearls for NEET-PG:** * **RA Hand Deformities:** Swan-neck deformity (PIP hyperextension, DIP flexion), Boutonniere deformity (PIP flexion, DIP hyperextension), and Z-deformity of the thumb. * **Joint Sparing:** If the DIP is involved, think OA or Psoriatic Arthritis. If the DIP is spared, think RA. * **Radiological Signs of RA:** Periarticular osteopenia, symmetrical joint space narrowing, and marginal erosions. * **Mnemonic:** **R**heumatoid **A**rthritis **R**ejects the **D**IP.

Question 1

All of the following are true about temporal arteritis except?

Accepted Answer

Low ESR

Answer

Polymyalgia rheumatica

Answer

Anemia

Answer

Sudden blindness

Question 2

Which of the following is/are not a feature of rheumatoid arthritis?

Accepted Answer

Osteophyte

Answer

Pannus formation in joint

Answer

Osteosclerosis and osteoclastic activity in underlying bone

Answer

Erosion of cartilage

Question 3

Tietze's syndrome usually develops at the costal cartilage of which ribs?

Accepted Answer

Second to fifth ribs

Answer

First and Second ribs

Answer

Sixth to Eighth ribs

Answer

All seven ribs

Question 4

Diffuse cutaneous systemic sclerosis is characterized by which of the following?

Accepted Answer

Early pulmonary fibrosis

Answer

Raynaud's phenomenon

Answer

Calcinosis cutis

Answer

Better long-term prognosis

Question 5

This type of lesion is most commonly seen in which disease?

Accepted Answer

Rheumatoid Arthritis (RA)

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Gout

Answer

Marfan syndrome

Question 6

Groton's sign is seen in which of the following conditions?

Accepted Answer

Dermatomyositis

Answer

Systemic Lupus Erythematosus (SLE)

Answer

Scleroderma

Answer

Mixed Connective Tissue Disease (MCTD)

Question 7

A 33-year-old woman has experienced episodes of fatigue, pleural effusion, pericardial effusion, carpal tunnel syndrome, and macrocytic anemia. What is the best test for diagnosis?

Accepted Answer

Assay for thyroid hormones

Answer

Anti-beta 2 phospholipid antibodies

Answer

Anti-smith antibody

Answer

Antinuclear antibody

Question 8

A 25-year-old woman presents with concerns about systemic lupus erythematosus, citing intermittent oral ulcers and right knee pain. She has no significant past medical history and uses only occasional ibuprofen. Physical examination reveals no alopecia, skin rash, or joint swelling. Her blood work shows a positive ANA at a titer of 1:40, with no other abnormalities. Which of the following statements is true?

Accepted Answer

Four diagnostic criteria are required for a diagnosis of systemic lupus erythematosus; this patient has two.

Answer

Four diagnostic criteria are required for a diagnosis of systemic lupus erythematosus; this patient has three.

Answer

If a urinalysis shows proteinuria, she will meet criteria for systemic lupus erythematosus.

Answer

The demonstration of a positive ANA alone is adequate to diagnose systemic lupus erythematosus.

Question 9

Which of the following is a feature of osteoarthritis?

Accepted Answer

Heberden node

Answer

Increased ESR

Answer

Onycholysis

Answer

Z deformity

Question 10

In which of the following conditions is the proximal interphalangeal joint involved while the distal interphalangeal joint is spared?

Accepted Answer

Rheumatoid arthritis

Answer

Osteoarthritis

Answer

Psoriatic arthritis

Answer

Ankylosing spondylitis

Rheumatology and Immunology — MCQs

Rheumatology and Immunology — MCQs

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