Medical Immunology Practice Questions-2016 Autoimmunity + Case Studies Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case. Janice Bond, a 31-year-old woman, presents with visual blurring and paresthesia (tingling in her arms and feet). She comments on experiencing unusual clumsiness and fatigue. She has increased motor tone (spasticity) and hyperreflexia. She cancels her follow up appointment the following week later because she feels better. Six months later, she reappears suddenly at your office complaining of visual blurring, tingling, significant weakness of her left leg and difficulties walking. You the following tests: Test Patient s values Normal values WBC 11.9 x 10 9 cells/l (3.3-11 x 10 9 cells/l) ESR 8 mm/hr (0-20 mm/hr) Rheumatoid factor 12 IU/ml (0-40 IU/ml) Antinuclear antibody (ANA) Neg (Neg) Anti-dsDNA 3 IU/ml (<25 IU/ml) Unirinalysis Normal (Normal) Cerebrospinal fluid (CSF) 8 cells/μl (<5 cells/μl) Tensilon test Normal (Normal) MRI (right) reveals lesions within the CNS (arrows). 1. Which of the following is the MOST LIKELY diagnosis from the list below? A. Diabetes B. Duchenne muscular dystrophy C. Goodpasture s syndrome D. Grave s disease E. Mitochondrial myopathy F. Multiple Sclerosis G. Myasthenia gravis H. Rheumatoid arthritis I. Systemic lupus erythematosus (SLE) 2. A Wright Stain of her cerebrospinal fluid would reveal predominantly: A. B cells B. Basophils C. Dendritic cells D. Endothelial cells E. Eosinophils F. Neutrophils G. T cells 3. Which of the following statements is MOST LIKELY to be true regarding Mrs. Bond s disease? A. A defect in negative selection in the thymus could not play a role in this disease B. Affects males more than female. C. Caused by an increase in TGF-β production D. Caused by an increase in IL-10 production E. Involves Th1 cells F. MHC class II alleles are not associated with disease G. Primarily due to antibodies against myelin Note: There will not be linked questions on an exam or quiz. However, this cluster of questions illustrates how you might need to think through the first question so that you could answer the second or third.
Use for the next 3 questions A 37-year-old man suffers a penetrating occupational injury to his left eye. After ophthalmic surgery and two weeks of uneventful healing, he notices redness, photophobia, pain, and significant visual impairment in his left eye and eventually in his right eye. Peripheral blood T cells and macrophages are isolated from the patient and mixed with an extract of bovine uveal tissue (from the eye) resulting in cellular proliferation. 4. Which of the following MOST LIKELY explains the reaction in the patient s right eye (sympathetic ophthalmia)? A. A cytokine imbalance. B. An immune response against normally sequestered antigens. C. An infection in the left eye has moved to the right eye resulting in polyclonal T cell activation by super antigens. D. Deletion of autoreactive T cells during negative selection. E. Molecular mimicry. F. The functional inactivation of mature T cells following TCR stimulation without a costimulatory signal. 5. What cell type is MOST LIKELY involved in this process? A. B cells B. Eosinophils C. Macrophages D. Mast cells E. Neutrophils F. T cells 6. What could/should be done to prevent him from losing site in his other eye? A. Antibiotic therapy. B. Immunosuppressive therapy with topical or systemic cortiosteroids. C. Induce polyclonal B cell activation by Epstein-Barr viral infection. D. Plasmapheresis. E. Treat with IL-2 or IL-12 to promote increased Th1 cell function. F. Treat with a super antigen. 7. Which mechanism do the following three disorders have in common Myasthenia Gravis, Grave s disease, Goodpasture s Syndrome? A. Antibody binding to a cell surface antigen B. Autoantibodies directed against soluble components. C. CD8+ cytotoxic action. D. Immune complex deposition and complement activation. E. Significant CD4+ T cell and macrophage infiltration.
Use for the next four questions 8. A 19-year-old SE Asian woman goes to her physician with a chief complaint of chronic weakness and tiredness for the past few months. Her joints were stiff and painful and she had a light red rash across her face. There was no evidence of infection, and she did not have gastrointestinal or respiratory complaints. A blood sample was taken for analysis. Test Patient s values Normal values White cell count 11.9 x 10 9 cells/l (3.3-11 x 10 9 cells/l) Hemoglobin 15.1 g/dl (13.5-17.5 g/dl) ESR 41 mm/hr (0-20 mm/hr) Rheumatoid factor 65 IU/ml (0-40 IU/ml) Antinuclear antibody Positive (Neg) Anti-dsDNA 75 IU/ml (<25 IU/ml) Unirinalysis Normal (Normal) Which of the following is the MOST LIKELY diagnosis from the list below? A. Goodpasture s syndrome B. Grave s disease C. Multiple Sclerosis D. Myasthenia gravis E. Rheumatoid arthritis F. Systemic lupus erythematosus (SLE) G. Type I Diabetes mellitus 9. The condition that the patient was diagnosed with can have many different manifestations. Which of the following is she the LEAST likely to develop? A. Anti-intrinsic factor antibodies. B. Autoreactive T cells that recognize histones providing anti-dsdna B cells with help. C. Decreased C3 levels D. Decreased CH50 levels with an increased ESR. E. Deposition of complement and IgG from skin biopsied from the site of the rash. F. Immune-complex deposits and neutrophil infiltration in the glomeruli of her kidney. G. Lymphadenopathy. H. Proteinuria due to altered membrane permeability. I. Rheumatoid factor. 10. Genetic abnormalities (i.e., null mutations) in have been noted to predispose one to this disease. A. C9 of complement B. Class II MHC C. Early components of complement or complement receptors D. IL-1 production E. Neutrophil generation of reactive oxygen intermediates (ROIs)
The patient enrolled in a clinical trial examining the role of monitoring and treatment in the long-term control of disease. The following table includes the results from one year of monitoring and treatment. The data were derived using an indirect agglutination test where latex beads were coated with dsdna and different dilutions of serum were added. Date Comments Dilution Unirinalys 1:1 1:4 1:16 1:64 1:256 1:1024 1:4096 is 1-24 Started study + + + - - - - neg. 2-25 + + + - - - - neg. 3-30 URI; increase immunosuppression - + + + + + - protein 4-21 Decrease immunosuppression + + + +/- - - - neg. 5-18 + + - - - - - neg. 6-23 + +/- - - - - neg. 7-25 + + - - - - - neg. 8-21 URI + + + + - - - neg. 9-22 + + + + - - - neg. 10-23 + + + +/- - - - neg. 11-22 + + + - - - - neg. 12-22 + + + - - - - neg. URI upper respiratory tract infection 11. Which day did the patient s serum contain the highest level of anti-histone antibodies? A. 1-24 B. 3-30 C. 4-21 D. 5-18 E. 10-23 Directions: Each of the numbered items or incomplete statements in this section is negatively phrased, as indicated by a capitalized word such as NOT, LEAST, or EXCEPT. Select the ONE lettered answer or completion that is BEST in each case. 12. In each of the following diseases, Th1 cells and/or cytotoxic CD8+ T cells appear to play major role(s) in tissue destruction, EXCEPT: A. Goodpasture s disease B. Hashimoto s thryroiditis C. Multiple sclerosis D. Rheumatoid arthritis E. Type I diabetes mellitus. 13. Each of the following statements is true regarding the pathogenesis of rheumatoid arthritis (RA), EXCEPT: A. CD4+ T cells appear to play a greater role than CD8+ T cells in the development of RA. B. RA is more common in women than in men. C. Rheumatoid factor (IgM anti-human IgG) is specific for Rheumatoid arthritis. D. Proinflammatory cytokines promote macrophage-induced release of lysomomal enzymes. E. Rheumatoid factor can induce complement activation within the joint. F. T cells stimulate autoreactive B cells.
14. Each of the following statements about systemic lupus erythematosus (SLE) is true, EXCEPT: A. Anti-inflammatory drugs are often used in treatment B. It can affect the heart, kidney and nervous system C. It can often be accompanied by an erythematous rash D. It predominantly affects young women E. There is no genetic susceptibility to the disease 15. Autoimmune diseases can be characterized by all of the following, EXCEPT: A. A tendency to occur more frequently in women B. Hypergammaglobulinemia (elevated Ig levels) C. Familiar incidence D. Autoantibodies in serum E. Elevated serum complement levels Use the extended matching format for the next set of questions Many autoimmune diseases are associated with antibodies reactive to normal self-components. Match the numbered autoimmune disease listed below with the autoantibody most closely associated with this disease. A. Acetylcholine receptor B. IgG C. Insulin receptor D. Intrinsic factor E. Myelin basic protein (MBP) F. Nuclear components G. Thyroid-stimulating hormone receptor H. None of the above 16. Myasthenia gravis 17. Goodpasture s syndrome 18. SLE 19. Grave s disease 20. Pernicious anemia ANSWERS: 1. F 2. G 3. E 4. B 5. F 6. B 7. A 8. F 9. A 10. C 11. B 12. A 13. C 14. E 15. E 16. A 17. H 18. F 19. G 20. D