Immunology RACP MCQs

Question 1

RACP 2022a Q5.
A patient is anaphylactic to egg products, which viral vaccine is
contraindicated for this patient?
a. Yellow fever
b. MMR
c. Influenza
d. Varicella

Answer 1

Answer A

Anaphylaxis to vaccine components
Yellow fever vaccine is contraindicated in people who have had:
anaphylaxisafter a previous dose of any yellow fever vaccine
anaphylaxisafter any component of a yellow fever vaccine
anaphylaxisto eggs

Question 2

RACP 2022a Q55

55.What increases risk of Stevens-Johnson syndrome in carbamazepine use?
a. HLAB5801
b. HLAB1502
c. CYP3A4 polymorphism
d. CYP2B6 polymorphism

Answer 2

Answer B

Carbamazepine-induced SJS–TEN is strongly associated with the HLA-B*1502 allele

Question 3

RACP 2022a Q71

71.What causes elevated triptan post anaphylaxis?
a. Mast cells
b. Steroids
c. Continued exposure to allergens

Answer 3

Answer A

Acute elevation of serum tryptase indicates degranulation of mast cells which occurs either due to an IgE-mediated mechanism, for example with penicillin allergy, or may result from direct degranulation of mast cells through non-IgE-mediated means, for example with NSAIDs or opiates

Question 4

RACP 2022b Q2

2. What is the reason for using ritonavir in co-formulation with lopinovir?
   A. Increases loponovir’s potency
   B. Inhibits liponavir metabolism
   C. Reduces lopinovir gastrointestinal toxicity
   D. Provides synergistic protease inhibition

Answer 4

Answer B

Lopinavir is metabolized by cytochrome P4503A (CYP3A) isoenzyme in the liver. Lopinavir is always used with ritonavir to reduce the dose of lopinavir and increase the plasma levels of lopinavir as ritonavir inhibits CYP3A isoenzyme. e small amount of ritonavir increases the bioavailability of the lopinavir

Question 5

RACP 2022b Q5

5. A patient with a history of ezcema develops itchiness, scaling and redness on her
   earlobes after wearing new earrings. She also reports a similar skin reaction to her
   jean button. You suspect a nickel allergy. What is the main mechanism causing this?
   A. Cell mediated
   B. Cytotoxic
   C. IgE
   D. Immune-antibody complex

Answer 5

Answer A

Allergic contact dermatitis represents the classic presentation of a T cell-mediated, delayed-type hypersensitivity response to exogenous agents. The initial step in the development of allergic contact dermatitis, as in nickel allergy, is hapten binding to a skin carrier protein. A hapten by itself is not immunogenic but becomes so after binding to a skin protein carrier. The hapten protein complex forms through covalent bonds between the hapten and amino acid side chains of target proteins within the skin.[8] The complex ultimately produces the sensitization of T cells. Sensitized T cells encountering the antigen at any time later will then lead to the release of cytokines, which in turn leads to macrophage activation and produces the immune response.[8] In summary, the sensitization process requires an initial exposure to allow the immune system to recognize the antigen later and lead to the immune response that causes ACD.

Question 6

RACP 2022b Q13
13. Dupilumab works on IL4Ra. Besides affecting IL-4 levels, what else does it affect?
A. IL-5
B. IL13
C. IL17
D. IL23

Answer 6

Answer B

Dupilumab is an interleukin-4 (IL-4) receptor alpha antagonist. It is a human monoclonal antibody of the immunoglobulin G4 subclass that inhibits IL-4 and interleukin-13 (IL-13) signalling by specifically binding to the IL-4 receptor alpha subunit, which is shared by the IL-4 and IL-13 receptor complexes. Dupilumab inhibits IL-4 signalling via the type 1 receptor and both IL-4 and IL-13 signalling via the type 2 receptor. By blocking the IL-4R alpha subunit, dupilumab inhibits IL-4 and IL-13 cytokine-induced responses, including the release of proinflammatory cytokines, chemokines, and immunoglobulin E.

Question 7

RACP 2022b Q29

29. Besides experiencing a previous allergy to Pfizer vaccine, what else is a
    contraindication to receiving the vaccine?
    A. Anaphylaxis to egg
    B. Latex
    C. Neomycin
    D. Polyethylene glycol

Answer 7

Answer D

The following people should be assessed to check they are suitable for vaccination:

people with immediate (within 4 hours) and generalised symptoms of a possible allergic reaction (such as urticaria/hives) to a previous dose of a COVID-19 vaccine, without anaphylaxis
people with a generalised allergic reaction (without anaphylaxis) to any component of the COVID-19 vaccine to be administered (such as PEG in Pfizer and Moderna, or polysorbate 80 in Novavax)
people with a history of anaphylaxis to previous vaccines or multiple drugs (injectable or oral) where a component such as PEG (for mRNA vaccines) or polysorbate 80 (for Novavax) may be the cause
people with a history of confirmed mastocytosis with recurrent anaphylaxis that requires treatment

Question 8

RACP 2022b Q42

42. Which immunoglobulin isotope is the most pathogenic as an auto-antibody?
    A. IgA
    B. IgG
    C. IgM
    D. IgD

Answer 8

Answer B OR C?

The presence of autoreactive antibodies is a hallmark of many autoimmune diseases. The effector functions of (auto)antibodies are determined by their constant domain, which defines the antibody isotype and subclass. The most prevalent isotype in serum is IgG, which is often the only isotype used in diagnostic testing

Question 9

RACP 2022b Q43

43. (Past question) Chimeric antigen receptor therapy utilises which type of cell?
    A. B cells
    B. T cells
    C. NK cells
    D. Macrophages

Answer 9

Answer B

CAR T cells are made by collecting T cells from the patient and re-engineering them in the laboratory to produce proteins on their surface called chimeric antigen receptors, or CARs. The CARs recognize and bind to specific proteins, or antigens, on the surface of cancer cells.

Question 10

RACP 2022b Q51

51. What is the trigger for alternate complement pathway?
    A) IgG and IgM binding
    B) Presence of sugars
    C) Lack of complement regulatory proteins

Answer 10

Answer B

This pathway is activated byviruses, fungi, bacteria, parasites, cobra venom, immunoglobulin A, and polysaccharidesand forms an important part of the defense mechanism independent of the immune response.

Question 11

RACP 2021a Q8.
Chimeric antigen receptor engineered cells are useful in treating some patients with haematological
malignancies. Which of the following is the main effector cell in this therapy?
A. B cells
B. Dendritic cells
C. NK cells
D. T cells

Answer 11

Answer D

CAR T cells are made by collecting T cells from the patient and re-engineering them in the laboratory to produce proteins on their surface called chimeric antigen receptors, or CARs. The CARs recognize and bind to specific proteins, or antigens, on the surface of cancer cells.

Question 12

RACP 2021a Q15.
A 34 year old man is newly diagnosed with HIV. His CD4 count is 726 and his viral load is >80000. He is HBV
and HCV negative, and asymptomatic and otherwise well. When is the most appropriate time to start treatment?
A. Now
B. CD4 <200
C. CD4 <500
D. CD4 <500 and viral load >100,000

Answer 12

Answer A

Question 13

RACP 2021a Q20.
A 45-year-old female who previously developed a rash after taking amoxicillin at the age of 5 years now has
streptococcal pneumonia. She has tolerated cephalosporins and roxithromycin previously without any reaction.
There is no family history of penicillin allergy.
Which of the following is the best indication to de-label her as having true penicillin allergy?
A. Age at which the reaction occurred
B. Tolerance to cephalosporins
C. Tolerance to roxithromycin
D. No family history of penicillin allergy

Answer 13

Answer A

Time elapsed since the reaction — The time elapsed since the last reaction is important because penicillin-specific IgE antibodies decrease over time, and therefore, patients with recent reactions are more likely to be allergic than patients with distant reactions [63-65]:

●Approximately 50 percent of patients with IgE-mediated penicillin allergy have lost the sensitivity 5 years after their last reaction.

●Approximately 80 percent of patients with IgE-mediated penicillin allergy have lost the sensitivity after 10 years.

Cephalosporins – Patients with a history of an immediate penicillin reaction who have tolerated one or more courses of cephalosporins subsequent to the penicillin reaction have proven themselves to not be allergic to cephalosporins, but they could still be allergic to penicillins. It is known that 98 percent of penicillin skin test-positive patients (to the major and/or minor penicillin determinants) are able to tolerate cephalosporins

Question 14

RACP 2021a Q42
A man presents after a single episode of unprotected receptive anal intercourse with a male partner who is
known to be HIV positive. His partner is compliant with taking triple antiviral therapy and had blood tests 1 week
ago showing his HIV viral load was <20.
What is the chance of HIV transmission?
A. 0.01%
B. 0.1%
C. 1%
D. 10%

Answer 14

Answer A

HIV is transmitted sexually, parenterally (contact or exposure of body fluids) or vertically (from mother to baby)

Sexual transmission is responsible for ~80% of cases worldwide

Undetectable viral load is defined as less than 200 copies of HIV per mL of blood.

Significantly reduces and in some cases eliminates chances of HIV transmission if viral load is undetectable.

Question 15

RACP 2021b Q103

Q103. The allergic reaction involved in serum sickness is primarily mediated by which of the following?
A. IgE
B. Antigen-antibody complexes
C. T lymphocytes
D. Complement activation

Answer 15

Answer D Type 3
Immune complex mediated

Question 16

RACP 2021 Oct Q9

9. When would you start prophylaxis for pneumocystis jiroveci pneumonia in a
   HIV +ve patient?
   a. CD4 count < 50
   b. CD4 count < 100
   c. CD4 < 400
   d. CD 4 < 200

Answer 16

Answer D

Question 17

RACP 2021 Oct Q28

When do b cells express CD20?
a. Plasma cell
b. Naïve B Cell
c. Mature B cell
d. Pro B cell

Answer 17

Answer C

CD20 (cluster of differentiate 20) is a protein that is expressed on the surface of B cells,starting at the pre-B cell stage and on mature B cells in the bone marrow and in the periphery. CD20 is not expressed on hematopoietic stem cells, pro-B cells, or normal plasma cells.

Question 18

RACP 2021 Oct Q82

82. What food allergy is implicated in exercise induced anaphylaxis?
    a. Soy
    b. Peanut
    c. Milk
    d. Wheat

Answer 18

Answer D

Food-dependent, exercise-induced anaphylaxis (FDEIA) – FDEIA is a disorder in which symptoms develop only if exercise takes place within a few hours of eating and, in most cases, only if a specific food to which the patient is sensitized is eaten in the pre-exercise period. It is the combination of the food (allergy) and exercise (cofactor) that precipitates attacks. Patients tolerate the culprit food in the absence of exercise, and they tolerate exercise in the absence of the culprit food. One of the most common food allergies to present as FDEIA is wheat allergy, or wheat-dependent EIA (WDEIA)

Question 19

RACP 2021 Oct Q84

84. Which cells are activated by Th17 lymphocytes?
    a. B lymphocytes
    b. Natural killer cells
    c. Neutrophil
    d. Dendritic cells

Answer 19

Answer C

Th17 cells represent a subset of CD4 effector T cells distinct from Th1 and Th2 lineages, and mediate powerful effects on stromal cells; this results in theproduction of inflammatory cytokines and recruitment of leukocytes, especially neutrophils, creating a link between innate and adaptive immunity

Question 20

RACP 2021 Oct Q107

107. What part of the complement system prevents C9 from binding to the
     membrane attack complex?
     a. CD59
     b. Protein H
     c. Protein I
     d. ?

Answer 20

Answer A

In order to protect themselves from the complement attack, the cells express several regulatory molecules, including the terminal complex regulator CD59 that inhibits assembly of the large MACs by inhibiting the insertion of additional C9 molecules into the C5b-9 complex.

Question 21

RACP 2020a Q3

3. Choose the appropriate marker for peripheral blood stem cell precursor
   A) CD19
   B) CD20
   C) CD34
   D) CD38

Answer 21

Answer C

CD34 ispredominantly regarded as a marker of hematopoietic stem cells (HSC) and hematopoietic progenitor cells

Question 22

RACP 2020a Q29

29. How often should patients on PrEP (pre-exposure prophylaxis) be screened for HIV?

A) 3 monthly
B) 6 monthly
C) 12 monthly
D) After every high risk exposure

Answer 22

Answer A

Question 23

RACP 2020a Q69.
In early disease, HIV binds to CD4 with which other co-receptor?

A) CCR5
B) CTLA4
C) CD3
D) CXCR4

Answer 23

Answer A

• HIV enters the body and attaches to cells with CD4 receptors via gp120 glycoprotein (on gp41 stalk).
• Viral envelope fuses with host cell – requires co-receptors CCR5 and CXCR4.
• Early stages – CCR5, later stages CXCR4

Question 24

RACP 2020a Q72
72. Beta 2 microglobulin is a key component of which immunological cell?

A) B cell
B) T cell
C) MHC I
D) MHC II

Answer 24

Answer C

Beta-2-microglobulin (β2-microglobulin) is a component of MHC (major histocompatibility complex) class I molecules, present onall nucleated cells(excludes red blood cells).

Question 25

RACP 2020a
73. What is the most important benefit of tenofovir alafenamide (TAF) compared to tenofovir disoproxil fumurate (TDF) in the treatment of human immunodeficiency virus or aquired immunodeficiency syndrome (HIV/AIDS)

A) Blockade of chemokine receptor type 5 (CCR5)
B) Elimination of nephrotoxicity
C) Improved efficacy as pre-exposure prophylaxis (PrEP)
D) Limited potential for drug resistance

Answer 25

Answer B

The nucleotide analogue tenofovir is used for the treatment of both HIV and hepatitis B, and for HIV pre-exposure prophylaxis. The original tenofovir disoproxil fumarate (TDF) version was developed at a dose of 300 mg once daily. A subsequent pro-drug formulation, tenofovir alafenamide (TAF), has been launched at doses of 10 or 25 mg once daily. The pharmacokinetics of TAF lead to a 6.5-times higher intracellular concentration of the phosphorylated moiety tenofovir diphosphate, and 91% lower serum concentration of tenofovir, compared to TDF. Given these pharmacokinetic differences, the dose of TAF can be far lower: Pharmacodynamic studies suggest that the lower tenofovir concentrations in plasma produced by TAF translate to reduced off-target exposure to the drug in the kidneys and bones, for example, with implications for adverse effect

Question 26

RACP 2020
79. Problem with V(D)J cause deficiency in which lymphocyte?

A) B cell
B) B cell, T cell
C) B cell, NK, T cell
D) T Cell

Answer 26

Answer B

V(D)J recombination defect results in severe combined immune deficiency (SCID) with a lack ofT and B lymphocytesThe V(D)J recombination is a DNA rearrangement process that generates the diversity of T and B lymphocyte immune repertoire. It proceeds through the generation of a DNA double-strand break (DNA-DSB) by the Rag1/2 lymphoid-specific factors, which is repaired by the non-homologous end joining (NHEJ) DNA repair pathway. V(D)J recombination also constitutes a checkpoint in the lymphoid development.

Question 27

RACP 2020b Q3

3. Immunosuppressed grandma minding baby grandson getting live varicella vaccine. What precautions would you advise for the grandmother?

A. No precautions required
B. Avoid baby if he develops a rash
C. Prophylactic aciclovir
D. Avoid baby for 4 weeks

Answer 27

Answer A

Varicella vaccine is strongly recommended for household contacts of people who are immunocompromised.
Transmission of the varicella vaccine virus strain is extremely rare and is likely to cause only mild disease in the person who is immunocompromised (seeAdverse events). This compares with the relatively high risk of severe varicella disease from exposure to wild-type varicella-zoster virus in people who are immunocompromised

Question 28

RACP 2020b Q30

30. What cytokine is most implicated in the pathogenesis of auto-inflammatory conditions such as familial mediterranean fever?

A) IL-1
B) TNF-a
C) IL-7
D) IFN-Gamma

Answer 28

Answer A

Familial Mediterranean Fever (FMF) is the most common monogentic autoinflammatory disease. FMF results from mutations in MEFV, which lead to a pro-inflammatory state andincreased production of Interleukin 1 beta subunit (IL-1b) by myeloid cells

Question 29

RACP 2019a

What is the marker for peripheral blood stem cells?

A. CD 19
B. CD 20
C. CD 34
D. CD 38

Answer 29

Answer C

CD34 ispredominantly regarded as a marker of hematopoietic stem cells (HSC) and hematopoietic progenitor cells

Question 30

RACP 2019a

What vaccination besides H. influzenzae, pneumoccoal and meningococcal would you give to an asplenic patient?
A. Bordetella
B. Rubella
C. Influenza
D. Varicella zoste

Answer 30

Answer C

Vaccinations recommended in asplenia
Haemophilus influenza b
Influenza
Meningococcal
Pneumococcal

Question 31

RACP 2019a
Down-regulation of MHC class I by tumour cells, exposes them to detection by what part of the immune system?
A. B cells
B. CD4
C. CD8
D. NK cells

Answer 31

Answer D

Natural killer (NK) cells express inhibiting receptors (iNKRs), which specifically bind MHC-I molecules on the surface of healthy cells. When the expression of MHC-I on the cell surface decreases, which might occur during certain viral infections and cancer, iNKRs lose inhibiting signals and the infected cells become target for NK cell activation (missing-self detection).

Question 32

RACP 2019b

Question 4
Absence of what predisposes to atopic dermatitis?
A. Collagen
B. Filaggrin
C. Keratin
D. Kallikrein

Answer 32

Answer B

Atopic dermatitis is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children but also affects adults, with an estimated worldwide prevalence in children of 5 to over 20 percent. A family history of atopy (eczema, asthma, or allergic rhinitis) and the loss-of-function mutations in the filaggrin (FLG) gene, involved in the skin barrier function, are major risk factors for atopic dermatitis

Question 33

RACP 2019b Question 13
Which innate immune cell does Interleukin-5 act on?
A. Monocytes
B. Eosinophils
C. Neutrophils
D. Mast cells

Answer 33

Answer B

In humans, interleukin-5 acts only oneosinophils and basophils, in which it causes maturation, growth, activation, and survival

Question 34

RACP 2019b

Question 39
In the context of allograft transplantation, which process may be triggered by donor APCs displaying donor antigens to recipient T Cells?
A. Acute cellular rejection
B. Humoral rejection
C. Graft-versus-host disease
D. T cell anergy

Answer 34

Answer A

The ability of recipient T cells to recognize donor-derived antigens, called allorecognition, initiates allograft rejection. Once recipient T cells become activated, they undergo clonal expansion, differentiate into effector cells, and migrate into the graft where they promote tissue destruction. In addition, CD4 T cells help B cells produce alloantibodies

Two distinct pathways of allorecognition. a Direct pathway of allorecognition. Dendritic cells migrate from the graft to secondary lymphoid tissues to activate T cells. b Indirect pathway of allorecognition. Graft proteins are processed by recipient dendritic cells and presented to T cells.

Question 35

RACP 2019b
Question 63
In allogeneic stem cell transplant for acute myeloid leukemia, anti-thymocyte antibodies (ATG) are routinely administered as part of the conditioning regime. What is the benefit of ATG?
A. Prevent graft versus host disease
B. Enhance graft versus leukemia effect
C. Bone marrow recovery
D. Prevention of infection

Answer 35

Answer A

Anti-thymocyte globulin (ATG), a polyclonal antibody, is used in allogeneic hematopoietic cell transplantation (HCT) to prevent graft-vs.-host-disease (GvHD) and graft failure (GF). Anti-thymocyte globulin is a polyclonal antibody against human T cells. It is a gamma immunoglobulin produced by immunising rabbits. As well as depleting T cells in the circulation, anti-thymocyte globulin is also thought to reduce T cell proliferation, homing and cytotoxic effects within the body
ATG induces the generation of regulatory T cells (Treg), both in vitro and in vivo.31–33 This is clinically relevant given accumulating evidence showing an important role for
Treg in GvHD prevention after allogeneic HCT

Question 36

RACP 2018b

107.Initiation of inflammation in acute gout is critically dependent upon which cytokine?
A. Interferon gamma.
B. Interleukin 1 beta.
C. Interleukin 13.
D. Interleukin 17.
E. Tumour necrosis factor.

Answer 36

Answer B

An acute attack of gout is a paradigm of acute sterile inflammation, as opposed to pyogenic inflammation. Recent studies suggest that the triggering of IL-1β release from leucocytes lies at the heart of a cascade of processes that involves multiple cytokines and mediators

Question 37

RACP 2018b
114.In patients undergoing acute rejection of the renal allograft, biopsy specimens are likely to
show predominant infiltration of the graft by which one of the following?
A. B-cells.
B. Dendritic cells.
C. Macrophages.
D. T-cells.
E. Natural killer (NK) cells.

Answer 37

Answer D

Acute renal allograft rejection is defined as an acute deterioration in allograft function associated with specific pathologic changes in the graft. There are two principal histologic forms of acute rejection, acute T cell-mediated (cellular) rejection (TCMR) and active antibody-mediated rejection (ABMR). ABMR and acute TCMR may coexist at the same time in the allograft

ABMR: Histological features of ABMR include arteriolar fibrinoid necrosis, fibrin thrombi in glomerular capillaries, glomerulitis, peritubular capillaritis, and interstitial hemorrhage. Also, the presence of peritubular capillary linear staining for C4d, which is a degradation product of the complement pathway that binds covalently to the endothelium, is highly suggestive of ABMR.

Acute T Cell-Mediated Rejection: Characterized by diffuse lymphocytic infiltration in the tubule, interstitium of the kidney, and in severe cases, vessels of the allograft

Question 38

RACP 2018b
130.What is the main purpose of somatic hypermutation in B cells?
A. Deletion of autoreactive B cells.
B. Expression of class II MHC.
C. Generation of receptor diversity.
D. Induction of anergy.
E. Selection of high affinity B cells.

Answer 38

Answer E

SHM in B cells provides the molecular basis for affinity maturation of antibodies. Affinity maturation: A process in which activated B cells interact with Th cells within the germinal center of secondary lymphoid tissue to secrete immunoglobulins with higher affinity for specific antigens

Question 39

RACP 2018b
141.Control of Mycobacterium tuberculosis (MTB) replication is dependent on a number of critical
factors including TNF alpha production and IFN gamma response.
Which other immune effector plays a major role in controlling MTB replication?
A. B cell.
B. Complement.
C. Natural killer cell.
D. Neutrophil.
E. T cell.

Answer 39

Answer E

The immune response against Mtb is related to the presence of Th1 cells, leading to the production of mediators such as IFN-γ, which activate infected macrophages.

The immune response to M tuberculosis is T cell dependent. It comprises not only the conventional CD4 and CD8 T cells, but also γδ T cells and CD1 restricted T cells. γδ T cells recognise phospholigands and no presentation molecules are known thus far.

Question 40

RACP 2018b
143.Tenofovir disoproxil fumarate is used in the management of HIV infection in combination with
other antiretrovirals. What is the site of action of tenofovir in the HIV life cycle?
A. HIV binding and entry of cells.
B. HIV protease activity.
C. HIV reverse transcriptase activity.
D. HIV viral assembly.
E. Integration of HIV DNA.

Answer 40

Answer C

Question 41

RACP 2018b
146.Defects in the interleukin 12-dependent interferon gamma pathways are most likely to lead to
infection with which organism?
A. Candida albicans.
B. Herpes simplex.
C. Neisseria meningitidis.
D. Non-tuberculous Mycobacterium.
E. Staphylococcus aureus.

Answer 41

Answer D

Interleukin 12 receptor beta 1 (IL12Rβ1) deficiency is a primary immunodeficiency resulting mainly in susceptibility toopportunistic infection by non-tuberculous, environmental mycobacteria and severe infection caused by Salmonella spp.

Question 42

RACP 2018b
150.Which acute-phase protein binds to phospholipid in foreign pathogens or damaged host cells?
A. C-reactive protein.
B. Ceruloplasmin.
C. Fibrinogen.
D. Mannose-binding lectin.
E. Serum amyloid A.

Answer 42

Answer A

A major function of CRP is its ability to bind phosphocholine, thereby permitting recognition both of foreign pathogens that display this moiety and phospholipid constituents of damaged cells. CRP can also activate the complement system and bind to phagocytic cells via Fc receptors, suggesting that it can initiate elimination of pathogens and targeted cells by interaction with both humoral and cellular effector systems of inflammation

Serum amyloid A binds to fibrin(ogen), promoting fibrin amyloid formation.

Ceruloplasmin binds to copper in the liver, circulates through the blood, and delivers the copper atoms to distant cells that use the atoms for basic processes

MBL binds to a range of sugars including N-acetyl-D-glucosamine, mannose, N-acetyl-mannosamine, fucose and glucose

Question 43

RACP 2018a Q15

15. A 19-year-old male is currently in hospital with his third episode of lobar pneumonia due to Streptococcus pneumoniae in the last 2 years. He reports a background of chronic sinus symptoms and frequent bronchitis, and takes 4–6 courses of antibiotics per year. He also reports intermittent nonbloody diarrhoea. Preliminary screening for immunodeficiency shows the following:

Pneumococcal antibodies: Normal values
Total IgG 14 mg/L [> 16]
IgG2 2 mg/L [> 5]
Immunoglobulins:
IgG 2.6 g/L [7–16]
IgA < 0.07 g/L [0.8–4.0]
IgM 2.5 g/L [0.4–2.5]
Lymphocyte subsets:
CD4+ 1023 cells/μL [500–1650]
CD8+ 477 cells/μL [210–1200]
NK 135 cells/μL [40–500]
CD19+ 0 cells/μL [80–600]
What is the most likely diagnosis?
A. Common variable immunodeficiency (CVID).
B. IgA deficiency.
C. Specific antibody deficiency.
D. X-linked agammaglobulinaemia.
E. X-linked hyper IgM syndrome.

Answer 43

Answer D

XLA is due to defects in a signal transduction molecule called Bruton tyrosine kinase (Btk). The diagnosis is suspected in a male patient with agammaglobulinemia/hypogammaglobulinemia, very low to absent CD19+ B cells, and a consistent clinical and/or family history.
CVID= reduced function of B cells not complete absence!

Question 44

RACP 2018a
59. A 42-year-old Sudanese male is diagnosed with advanced HIV with a CD4 count of 50 cells/μL
[650–2000] and a viral load of 100,000 copies per mL. He is commenced on once daily
antiretroviral. Baseline screening demonstrates he is Epstein–Barr virus (EBV) IgG positive and Toxoplasmosis IgG positive.
One month after commencing treatment he develops fever and cervical lymphadenopathy.What is the most likely cause for his lymphadenopathy?
A. Drug reaction.
B. Glandular fever.
C. HIV-related lymphadenopathy.
D. Immune reconstitution inflammatory syndrome (IRIS).
E. Sarcoidosis.

Answer 44

Answer D

The term “immune reconstitution inflammatory syndrome” (IRIS) describes a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes following the initiation of antiretroviral therapy (ART) in HIV-infected individuals. Diagnosis of IRIS requires the worsening of a recognized (“paradoxical” IRIS) or unrecognized preexisting infection (“unmasking” IRIS) in the setting of improving immunologic function. Most patients with IRIS develop symptoms within one week to a few months after the initiation of ART

Question 45

RACP 2018a
61. A 40-year-old HIV positive man with a CD4 count of 450 cells/μL [650–2000] presents with a 3 day history of fever, cough, sputum production and a right lower lobe consolidation on chest x-ray.
What is the most likely organism causing his pneumonia?
A. Methicillin resistant Staphylococcus aureus.
B. Mycobacterium avium complex.
C. Mycobacterium tuberculosis.
D. Pneumocystis jirovecii.
E. Streptococcus pneumoniae.

Answer 45

Answer E

Question 46

RACP 2018a
66. A 31-year-old woman has a history of facial swelling with ibuprofen and aspirin. After spraining her ankle she took paracetamol 1 g four times daily, and on the third day she woke up with swollen eyelids and upper lip swelling.
What is the best explanation for this?
A. High-dose paracetamol inhibits COX-1.
B. Paracetamol causes direct release of mast cell contents.
C. She has an IgE-mediated reaction to an excipient common to all three medications.
D. She has an underlying non-allergic condition causing angioedema.
E. The paracetamol has been cross-contaminated with aspirin or ibuprofen.

Answer 46

Answer A

Approximately 20 percent of patients with aspirin-exacerbated respiratory disease react to acetaminophen at a dose of 1000 mg [24], since acetaminophen weakly inhibits COX-1 at higher doses. Patients with AERD are usually identifiable clinically by the presence of concomitant asthma and chronic rhinosinusitis..

Question 47

RACP 2018a
69. Patients with drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) are most likely to have additional involvement of which system in addition to the skin?
A. Cardiovascular.
B. Hepatic.
C. Neurological.
D. Renal.
E. Respiratory.

Answer 47

Answer B

Organ involvement – Involvement of one or multiple organs occurs in most patients with DRESS. Liver injury is most common, occurring in up to 90 percent of cases. Acute interstitial nephritis, interstitial pneumonia, and, less commonly, myocarditis can also occur

Question 48

RACP 2018a
83. What is the main reason why immunotherapy (desensitisation) is routinely offered to patients with anaphylaxis caused by insect venom, but not to patients with anaphylaxis caused by food?
A. Desensitisation has no effect on food allergies.
B. Greater diversity of allergenic epitopes with foods.
C. Oral administration is less likely to induce tolerance.
D. Risk of anaphylaxis is higher with foods.
E. Sustained tolerance is harder to achieve with foods.

Answer 48

Answer E

Only a minority of patients treated with OIT (oral immunotherapy) achieve sustained unresponsiveness (SU) that is independent of regular food intake and is maintained even if the food is eliminated from the diet for long periods of time. Thus, for most allergens, it appears that OIT would need to be continued indefinitely to maintain a protective effect.

Question 49

RACP 2018a
86. In addition to cytotoxic T cells, which other immune cell is primarily dysfunctional in the pathophysiology of haemophagocytic lymphohistiocytosis?
A. Dendritic.
B. Macrophage.
C. Mast.
D. Natural killer.
E. T helper.

Answer 49

Answer B

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of multi-organ failure caused by unchecked macrophage- and lymphocyte-mediated inflammation. Underlying causes include inherited disorders of perforin-mediated cell-killing (primarily in infants/young children) and malignant, infectious, and autoimmune conditions in others

Question 50

RACP 2017
Question 17
25-year-old man is found to have co-infection with HIV and HBV. Serology confirms active replication with HB eAg and HBV DNA load. What combination of two drugs will treat HBV and form the backbone of HIV treatment for this man?
A. Abacavir and Lamivudine
B. Lopinavir and Ritonavir
C. Daclatasvir and Sofosbuvir
D. Lamivudine and Dolutegravir
E. Tenofovir and Emtricitabine

Answer 50

Answer E

Because emtricitabine (FTC), lamivudine (3TC), tenofovir (TDF) and Tenofovir Alafanemide (TAF) have activity against both HIV and HBV, antiretroviral therapy should be initiated with a combination which includes TDF or TAF in the nucleoside reverse transcriptase inhibitor (NRTI) backbone of a fully suppressive antiretroviral regimen.
If TDF or TAF cannot safely be used, the alternative recommended HBV therapy is entecavir in addition to a fully suppressive ARV regimen(BI).

Question 51

RACP 2017

What is the role of PD-1 (Programmed cell death protein) and PD-1 ligand antibodies?

A. B cell activation
B. NK cell inhibition
C. NK cell activation
D. T cell inhibition
E. T cell activation

Answer 51

Answer D

Under normal physiological conditions, the major function of PD-1 is toinhibit effector T-cell activity and enhance the function and development of Tregs, which inhibit T-cell responses and prevent overstimulation of immune responses in peripheral tissues.
CTLA-4 is thought to regulate T-cell proliferation early in an immune response, primarily in lymph nodes, whereas PD-1 suppresses T cells later in an immune response, primarily in peripheral tissues

Question 52

RACP 2017
Which of the following is the target of the monoclonal antibody Bevacizumab?
A. EGFR
B. TNF alpha
C. VEGF
D. PD-1
E. CD20

Answer 52

Answer C

Angiogenesis is important for tumour growth and metastasis and is an important target for new biological agents. Bevacizumab is a humanized recombinant antibody that prevents vascular endothelial growth factor (VEGF) receptor binding and inhibits angiogenesis and tumour growth.

Question 53

RACP 2017

What component of the immune system is most important in eliminating intracellular pathogens?

A. Complement
B. Antibodies
C. Eosinophils
D. T lymphocytes
E. Tumour Necrosis Factor

Answer 53

Answer ? D

Cytotoxic T lymphocytes (CTLs) play an important role in eliminating intracellular bacteria.
Natural killer (NK) cellsplay an essential role in killing intracellular pathogens through either cytotoxic attack of infected target cells or activation of macrophages via gamma interferon (IFN-γ) production.

Question 54

RACP 2017

Question 40
What is the action of CTLA-4 on T cells?

A. Activates T cells
B. Inhibits activation of T cells
C. Allows B and T cell co-stimulation
D. Allows interaction between complement and T cells
E. Promotes antibody production

Answer 54

Answer B

CTLA-4 is a molecule expressed on T cells after activation and strongly binds to co-stimulatory molecules on antigen-presenting cells that prevent binding of these molecules needed for T-cell activation. The CTLA-4 moleculeacts as a halting mechanism, decreasing the function of T cells.

Question 55

RACP 2017

Which of the following antibodies is most effective at fixing complement?
A. IgA
B. IgD
C. IgE
D. IgG
E. IgM

Answer 55

Answer E

The process of binding to C1, triggering activation of the classical pathway, and promoting assembly of the terminal membrane attack complex (MAC)is the process of complement fixation.
Complement fixation to IgM isstronger (>1000 times/antibody molecule) than that to IgG.

Question 56

RACP 2017
Which of the above options describes the mechanism of action of the medications below?
Question 63
Mycophenolate Mofetil.
Options
a) Inhibition of Dihydroorotate dehydrogenase
b) Inhibition of inosine monophosphate dehydrogenase
c) Inhibition of dihydrofolate reductase
d) Regulate the expression of genes responsible for inflammatory mediators
e) Inhibition of calcineurin
f) Inhibition of CD25
g) Binding to CD3
h) Inhibition of Tumour Necrosis Factor

Answer 56

Answer B

Mycophenolate mofetil (MMF, CellCept) is a prodrug of mycophenolic acid (MPA), an inhibitor of inosine-5’-monophosphate dehydrogenase.MPA depletes guanosine nucleotides preferentially in T and B lymphocytes and inhibits their proliferation, thereby suppressing cell-mediated immune responses and antibody formation.

Question 57

RACP 2017
Which of the above options describes the mechanism of action of the medications below?
Question 64
Prednisone.

Options
a) Inhibition of Dihydroorotate dehydrogenase
b) Inhibition of inosine monophosphate dehydrogenase
c) Inhibition of dihydrofolate reductase
d) Regulate the expression of genes responsible for inflammatory mediators
e) Inhibition of calcineurin
f) Inhibition of CD25
g) Binding to CD3
h) Inhibition of Tumour Necrosis Factor

Answer 57

Answer D

a) Inhibition of Dihydroorotate dehydrogenase – Leflunomide
b) Inhibition of inosine monophosphate dehydrogenase – Mycophenolate mofetil
c) Inhibition of dihydrofolate reductase – Methotrexate
d) Regulate the expression of genes responsible for inflammatory mediators – prednisone
e) Inhibition of calcineurin – Tacrolimus, cyclosporine
f) Inhibition of CD25 - Basiliximab Dacilizumab
g) Binding to CD3 - otelixizumab, teplizumab and visilizumab
h) Inhibition of Tumour Necrosis Factor- adalimumab, certolizumab, etanercept, golimumab, and infliximab

Question 58

RACP 2018b
22. In addition to removing the cause, what is the immediate treatment for anaphylaxis?
A. Adrenalin 0.1 mg IV.
B. Adrenalin 0.5 mg IV.
C. Adrenalin 0.5 mg IM.
D. Adrenalin 1 mg IM.
E. Adrenalin 5 mg nebulised.

Answer 58

Answer C

Question 59

The allergic reaction involved in serum sickness is mediated by which of the following?
A. IgE
B. Antigen-antibody complexes
C. T lymphocytes
D. Complement activation

Question 60

RACP 2022 Q45

Thunderstorm asthma is triggered in people with allergy to which allergen
A. Birch
B. Olive
C. Rye grass

Answer 60

Answer C

Thunderstorm asthmais when asthma symptoms are caused byrye grasspollen allergy during springtime thunderstorms.

Question 61

RACP 2016

Question 12
40 year old male with SJS due to amoxicillin (conjunctivitis, rash, penile and mucosal involcement). He improves once amoxicillin is ceased. In consultation with an allergy specialist, you recommend:
A. Organise testing of IgE levels against amoxicillin
B. Lifetime avoidance of beta lactam antibiotics
C. Intradermal skin prick testing for amoxicillin
D. Oral rechallenge with amoxicillin in a supervised environment
E. Desensitisation to amoxicillin

Answer 61

Answer B

Recurrent SJS/TEN with readministration of the causative drug or closely, chemically related agents has been widely documented in multiple case reports .The risk of recurrent SJS/TEN with structurally distinct agents (within the same therapeutic class of drugs) is unknown but probably very low.

Question 62

RACP 2016
Question 55
A 45 year old male gardener is stung by a bee and suffers and anaphylactic reaction. What is the best ongoing management?

A. Avoid going outside
B. Desensitisation therapy to bee stings
C. Protective clothing
D. Prophylactic steroids and antihistamines
E. No action required

Answer 62

Answer B

Upon discharge, any patient with symptoms of a systemic allergic reaction or anaphylaxis should receive both of the following:

-Anepinephrineautoinjector and instructions about how and when to use it

-Referral to an allergy specialist to determine if he/she is a candidate for venom immunotherapy, which is the definitive treatment for venom allergy. Venom immunotherapy reduces the risk of a recurrent life-threatening reaction to a subsequent sting to less than 5 percent. Allergy specialists can also provide patients with detailed advice about strategies for avoidance.

Question 63

RACP 2016 Question 83.
An 18 year old girl presents with Neisseria meningitidis bacteraemia. On further investigation, she has had recurrent similar episodes of meningitis for 10 years.
Which is the most important diagnosis to exclude?
A. Chronic granulomatous disease
B. Common variable immunodeficiency
C. Hyper IgE
D. IgA deficiency
E. Membrane attack complex deficiency

Answer 63

Answer E

The membrane attack complex / MAC plays an important role in neutralizing Neisseria and deficiencies thereforepredispose to infection with meningococci and gonococci. Deficient individuals typically present after the age of ten with recurrent episodes of meningococcal meningitis.

Question 64

RACP 2016

Question 3
Compared to adaptive immune system, one ofthe cardinal features of innate immune system is:
A. Diversity
B. Inflammation
C. Memory
D. Specificity
E. Self-tolerance

Answer 64

Answer ?B

Adaptive immune system is antigen specific, has immunological memory and diversity of receptors to recognize millions of antigen epitopes.
Innate immune system is rapid, antigen independent and leads to inflammation

Question 65

RACP 2016 Question 5
The C-reactive protein (CRP) is a commonly requested test in the investigation of fever. Where in the immune system does CRP work?
A. Adaptive immune system
B. Antigen presentation
C. Complement
D. Innate immune system
E. Leukocyte adhesion.

Answer 65

Answer D

CRP belongs to a family of pentraxins – which are circulating pattern recognition receptors.
A major function of CRP is its ability to bind phosphocholine, thereby permitting recognition both of foreign pathogens that display this moiety and phospholipid constituents of damaged cells.
CRP plays arole in inflammationby​
Activating C1q – classic complement pathway – leads to opsonization,phagocytosis​
Binds to Fc portion of Ig – activates release of inflammatory cytokines​
Acts as a PRR – recognize PAMPs/DAMPs

Question 66

RACP 2016
Question 24
If MHC class 1 expression is downregulated by a virus, which of the following cells will be unable to act?
A. CD19 lymphocytes
B. CD4+ T cells
C. CD8+ T cells
D. Dendritic cells
E. NK cells

Answer 66

Answer C

In humans as in other animal species, CD8+cytotoxic T lymphocytes (CTLs) play an important if not the major role in controlling virus-infected and malignant cell growth. The interactions between CD8+T cells and target cells are mediated by human leukocyte antigen (HLA) class I antigens loaded with viral and tumor antigen-derived peptides along with costimulatory receptor/ligand stimuli. Thus, to escape from CD8+T-cell recognition and destruction, viruses and tumor cells have developed strategies to inhibit the expression and/or function of HLA class I antigens. In contrast, cells with downregulated MHC class I surface expression can be recognized by NK cells, although NK cell-mediated lysis could be abrogated by the expression of inhibiting NK cell receptors

Question 67

RACP 2015a

Question 9
A 16 year old male presents with recurrent sinus infections on the background of three
previous ICU admissions for pneumonia. His investigations are as follows:
Mild anaemia
Normal WCC and differential (multiple B and T cell lineage markers given, all normal)
Normal platelets IgG mild-moderately low compared to reference range IgM very low compared to reference range. All other immunoglobulin levels unremarkable
What is the most likely diagnosis?
A. Chronic granulomatous disease
B. Common variable immunodeficiency
C. Leukocyte adhesion deficiency
D. Severe variable immunodeficiency
E. X linked agammaglobulinemia

Answer 67

Answer B

CVID - Common variable immunodeficiency (CVID) is the most common form of severe antibody deficiency affecting both children and adults. The characteristic immune defect in CVID is impaired B cell differentiation with defective production of immunoglobulin. CVID is defined by low total serum concentrations of immunoglobulin (Ig)G, as well as low IgA and/or IgM, poor or absent response to immunization, and the absence of any other defined immunodeficiency state.Bacterial infections of the sinopulmonary tract, particularly sinusitis and pneumonia, are experienced by most patients with CVID

Question 68

RACP 2015b

In renal allograft rejection, what is the primary cell involved?
A. B lymphocytes
B. T lymphocytes
C. NK cells

Answer 68

Answer B

Both innate and adaptive immune systems play a significant role in rejection, but the T lymphocytes are the principal cells that recognize the allograft

Question 69

RACP 2015b
Acquired angioedema in autoimmune systemic diseases due to failure of inhibition of which component of the complement cascade:
A. Alternative pathway
B. Classical pathway
C. Factor H
D. Mannose Lectin pathway
E. Terminal attack complex

Answer 69

Answer B

Acquired angioedema (AAE) is characterized by acquired deficiency of C1 inhibitor (C1-INH), hyperactivation of the classical pathway of human complement and angioedema symptoms mediated by bradykinin released by inappropriate activation of the contact-kinin system.

Question 70

RACP 2015b

Question 41
Hereditary angioedema which complement pathway:
A. Classic
B. Alternative
C. Lectin
D. Common
E. Rhubarb

Answer 70

Answer A

Most cases of hereditary angioedema (HAE) are caused by a deficiency or dysfunction of C1 esterase inhibitor (C1-INH), resulting in the inability to regulate the contact system. C1-INH inhibits plasma kallikrein and coagulation factor XIIa.Low levels of C1 inhibitor, the main inhibitor of the classic complement system, result in paroxysmal angioedema attacks.

Question 71

RACP 2015b
Question 55
Which of the following would be the most likely investigation to diagnose primary
immunodeficiency in a 25year old lady who presents with recurrent sinopulmonary
infections?
A. A THC/CH50
B. B IgM
C. C IgG
D. D CD4 count
E. E CD8 count

Answer 71

Answer C

Common variable immunodeficiency (CVID) is the most common form of severe antibody deficiency affecting both children and adults. The characteristic immune defect in CVID is impaired B cell differentiation with defective production of immunoglobulin. CVID is defined by low total serum concentrations of immunoglobulin (Ig)G, as well as low IgA and/or IgM, poor or absent response to immunization, and the absence of any other defined immunodeficiency state. Bacterial infections of the sinopulmonary tract, particularly sinusitis and pneumonia, are experienced by most patients with CVID.
The diagnosis of CVID requires a suggestive clinical history, a reduced total serum concentration of IgG, plus low IgA or IgM, and poor responses to both protein- and polysaccharide-based vaccines.

Question 72

RACP 2015b

What is the mechanism of action of Ipilimumab?
A. Cytotoxic T Lymphocyte Inhibitor
B. Cell check point modulator
C. Vascular Endothelial Growth Factor Inhibitor
D. Interleukin 2 Inhibitor
E. Rhubarb

Answer 72

Answer A

Ipilimumab is an anti-CTLA-4 monoclonal antibody that prevents CD80 and CD86 on APCs from binding to CTLA-4 on T cells. This blockage of CTLA-4 signaling allows T-cell activation, proliferation, and amplification of T-cell-mediated immunity, which allows the patient’s immune system to mount a better response

Question 73

RACP 2015b

Question
The yellow fever vaccine is a live attenuated vaccine. In which of the following situations is it safe to give the yellow fever vaccine?
A. Asplenia
B. Giant cell arteritis on 25mg/d prednisone for last 3 months
C. HIV with CD4 count of 180
D. Pregnancy
E. Rhubarb

Answer 73

Answer A

Vaccine-related disease can be caused by unchecked infection (replication) by the live vaccine virus or bacteria. This is especially true for: BCG, MMR and VZV

• have HIV - (CD4+ count of >200 per µL) can receive yellow fever vaccine if they are at risk of infection. People with HIV should only receive yellow fever vaccine if potential exposure to yellow fever virus is unavoidable.
• are taking highly immunosuppressive therapy, including bDMARDs or tsDMARDs (biological or targeted synthetic disease-modifying anti-rheumatic drugs), or high-dose corticosteroids (> 20 mg/day for >14 days)
• Pregnant women - Yellow fever vaccine is not recommended, other than in exceptional circumstances
• Asplenia alone is not a contraindication for any vaccination, including live vaccines.

Question 74

RACP 2015b

Question
A woman in her 30s presents 90 days post renal transplant. The post-operative course has thus far been unremarkable. She is febrile with malaise and rigors. Her medications include tacrolimus, MMF, prednisone, valganciclovir and Bactrim.
What is the most likely aetiology?
A. BK (polyoma) virus
B. CMV
C. E coli
D. Rhubarb
E. Rhubarb

Answer 74

Answer A vs C

Question 75

RACP 2014a Q4

Question 4:
A female with recurrent attacks of facial and lip swelling without rash, presents to hospital after her fifth attack. She states that she awoke from sleep with her current symptoms. She has been unable to identify any triggers. What investigation would be most useful in identifying the cause of her symptoms?
1. Eosinophils
2. Tryptase level
3. IgE
4. IgE to peanut
5. C4

Question 76

RACP 2014a Q21

21. Which of the following malignancies occurs more frequently in patients with CVID?
    a) Gastric adenocarcinoma
    b) Multiple Myeloma
    c) Lymphoma
    d) Kaposi’s sarcoma
    e) Squamous cell carcinoma

Question 77

RACP 2014a

Question 30
Which condition leads to near absent B cells?
a) Common variable immunodeficiency
b) Chronic granulomatous disease
c) X-linked agammaglobulinaemia

Question 78

RACP 2014a Q33

C - reactive protein is something we commonly measure. In which system does it play it’s role?
A - Innate immunity
B - Antigen presenting system
C - Adaptive immunity
D - Complement system

Question 79

RACP 2014 Q77

What is responsible for periodic fever syndrome?

A. Neutrophil
B. Inflammasome
C. NK cell
D. T cell
E. B cell

Question 80

RACP 2014 Q6

Question 6

Omission of which of the following aspects of management of anaphylaxis is likely to have the most deleterious effect?

a. Adrenaline

b. Antihistamine

c. Corticosteroid

d. Fluid resuscitation

e. Bronchodilators

Question 81

RACP 2013a Q32

Question 32
The most important event in complement dependent cytotoxicity is:
A) Fc receptor binding to membrane bound antigens
B) Something about membrane lipid rafts ??
C) Fas-Fas ligand induced apoptosis
D) Formation of membrane attack complex
E) Perforin mediated cytolysis

Question 82

RACP 2013 Q 30
Question 30
A patient with newly diagnosed partial epilepsy is commenced on carbamazepine. 2 weeks later, she
develops a maculopapular rash. What is the predominant cell type involved in this reaction?
A. T cells
B. IgG
C. Complement
D. IgE
E. B cells

Question 83

RACP 2012a QUESTION 11
What is the most common B Cell deficiency disorder?
A. Di George syndrome
B. Common variable immunodeficiency
C. X linked agammaglobulinemia (XLA)
D. Severe combined immunodeficiency
E. X linked lymphoproliferative disease

Question 84

RACP 2012a QUESTION 47
Patients who have had an allogeneic stem cell transplant are more likely to get invasive fungal infections with pathogens such as aspergillus fumigans and
scedosporium. Which host factor is the most likely cause of this?
A. Corticosteroids
B. Diabetes mellitus
C. Graft versus Host disease
D. Prior lung disease
E. Prolonged neutropenia

Question 85

RACP 2012a QUESTION 57
You suspect a patient has a T cell immunodeficiency. The recurrence of which
infection would support this?
A. Candida albicans - Oesophagitis
B. Neisseria meningitidis - Meningitis
C. Staph aureus - Furunculosis
D. Strep pneumoniae - Pneumonia
E. Gardnerella vaginalis - Vaginosis

Question 86

RACP 2012a QUESTION 70
Cytotoxic chemotherapy is given in cycles to allow bone marrow recovery.
In a regimen of intravenous chemotherapy given on day one of a 21 day cycle;
which days will correspond to the neutrophil nadir?
A. 1 – 4 days
B. 5 – 9 days
C. 10 – 14 days
D. 15 – 18 days
E. 19 – 21 days

Question 87

RACP 2012b QUESTION 36
A 45 year old lady has a history of bloody diarrhoea two weeks previously which was
treated with Amoxil. She now presents with lethargy and a petechial rash on her
lower limbs
Creatinine 670
Hb 81
WCC 3.4
Platelets 120
C3 and C4 normal
The blood film showed a left shift with schistocytes.
What is the most likely diagnosis?
A. HUS
B. Henoch shoenlein
C. Vasculitis
D. SLE
E. Cryoglobulinaemia

Question 88

RACP 2012b QUESTION 36
A 45 year old lady has a history of bloody diarrhoea two weeks previously which was
treated with Amoxil. She now presents with lethargy and a petechial rash on her
lower limbs
Creatinine 670
Hb 81
WCC 3.4
Platelets 120
C3 and C4 normal
The blood film showed a left shift with schistocytes.
What is the most likely diagnosis?
A. HUS
B. Henoch shoenlein
C. Vasculitis
D. SLE
E. Cryoglobulinaemia

Question 89

RACP 2012b QUESTION 49
A patient with chronic immune thrombocytopaenic purpure (ITP) with a platelet count of 30 underwent urgent cholecystectomy for cholecystitis. Which of the following will
reduce the risk of perioperative bleeding?
A. Platelet transfusion
B. Intravenous immunoglobulin
C. Prednisone
D. Rituximab
E. Thrombopoietic stimulating agonist

Question 90

RACP 2012b QUESTION 68
A patient has developed fever, arthralgia, abdominal pain and painful rash (shown
below):

Biopsy of this rash demonstrates leucoplastic changes and fibrotic necrosis.
On direct immunofluorescence of the skin biopsy, demonstration of which of the
following will confirm the diagnosis?
A. C3
B. IgG
C. IgM
D. IgA
E. Fibrinogen

Question 91

RACP 2012b QUESTION 80
A 46 year old has a history of throat swelling to cephalexin 20 years previously. He
has been diagnosed with endocarditis - Strep viridians sensitive to
penicillin. What should you do?
A. Oral challenge to penicillin
B. Skin prick testing to penicillin
C. Commence meropenem
D. Commence vancomycin
E. Immediately desensitise to penicillin

Question 92

RACP 2012b QUESTION 87
Which of the following is the highest risk factor for death in anaphylaxis?
A. Age
B. Hypertension
C. Chronic Urticaria
D. Uncontrolled Asthma
E. Crustacean (seafood) allergy

Question 93

RACP 2012b QUESTION 100.
A nurse receives a needlestick injury during an operation on an HIV positive patient
who has a high viral load and is known to have been non-compliant with his
antiretroviral medication. What is the best course of action?
A. Await results of HIV genotype resistance testing prior to treatment
B. Enrol the nurse in a clinical trial of post-exposure prophylaxis
C. Treat with antiretroviral drugs that the patient has not previously been
exposed to
D. Treat with the same antiretroviral drug regime that the patient is currently on
E. Reassure the nurse that the risk of transmission from such a needlestick injury
is low

Question 94

RACP 2011a Question 32

What is the mechanism by which NK cells kill virally infected cells?

A. Lysis of host cells lacking MHC expression
B. Recognition of conserved viral particles
C. Opsonisation of viral cells
D. Activation of complement cascade
E. Binding to Toll-like receptors on the cell surface

Question 95

RACP 2011a Question 46

A young man presents with recurrent mild meningococcal infections. The test most likely to diagnose a primary immunodeficiency is:

A. CD4 count
B. CD8 count
C. Immunoglobulin levels
D. Nitroblue tetrazolium test
E. Total haemolytic complement (THC or CH50)

Question 96

RACP 2011a Question 53

Anaphylaxis is mediated by:

A. Cross linking of mast cell IgE

B. Secretion of IgE by B cells in response to allergen

C. B cell secretion of interleukin-13(?)

D. Direct release of preformed histamine and cytokines from mast cells

E. Spontaneous release of granulocyte content (?)

Question 97

RACP 2011a Question 64

Common variable immunodeficiency (CVID) is the most common primary immunodeficiency in adults. What best explains its pathogenesis?

A. Absence of co stimulatory signal between B and T cells (CD40/CD40L)
B. Absent neutrophil respiratory burst
C. Dysfunctional T cell signalling cascade
D. Maturation arrest during B cell development
E. Absent or reduce circulating B cells

Question 98

RACP 2011b Question 37

A 35yr old man with advanced AIDS presents with a left hand motor seizure. CT brain with contrast reveals a 3cm enhancing lesion within the right frontal lobe. The most likely diagnosis is:

A. Glioma
B. Meningioma
C. Primary cerebral lymphoma
D. Secondary cerebral lymphoma
E. Secondary cerebral Kaposi’s sarcoma

Question 99

RACP 2011b Question 45

A female patient with has recurrent lobar pneumonia and sinopulmonary infections. She has the following blood tests:

Serum total IgG 158 mg/dL [768 – 1632]
Serum IgA 35 mg/dL [68 – 378]
Serum IgM 79 mg/gL [60 – 263]
IgG1 109 mg/dL [240 – 1118]
IgG2 35 mg/dL [124 – 549]
IgG3 11 mg/dL [21 – 134]
IgG4 3 mg/dL [7 – 89]
T cell count normal
B cell count normal

Her most likely immunodeficiency syndrome is:
A. Common variable immunodeficiency
B. IgG subclass deficiency
C. IgA deficiency
D. Human immunodeficiency virus (HIV)
E. Severe combined immunodeficiency

Question 100

RACP 2011b Question 48

A male patient with a history of intravenous drug use presents with a rash, myalgias, arthralgias. He is afebrile. He is positive to hepatitis C antibody and rheumatoid factor. He C4 complement level is reduced with normal C3 levels. His ANA is positive at 1:160 speckled. His rash is shown below:

What is the most likely diagnosis?
A. Cryoglobulinaemic vasculitis
B. Henosch-schonlein purpura
C. Rheumatoid vasculitis
D. Subacute bacterial endocarditis
E. Meningococcal disease

Question 101

RACP 2011b Question 51

A 65 year old male with longstanding asthma presents with cough, dypsnoea and a right 6th cranial nerve palsy. A CT scan shows diffuse and patchy ground glass changes.

His blood tests are shown:
Hb 109 [130-180]
WCC 14 [4-11]
Plt 480 [150-400]
ANCA positive
Anti-myeloperoxidase (MPO) 99 [<5]
ESR 100 [0-5]
CRP 30 [0-5]
Anti-dsDNA 5 [0-6]
ANA 1:160 speckled
Urinalysis trace blood, no protein

The most likely diagnosis is:
A. Allergic bronchopulmonary aspergillosis (ABPA)
B. Churg-Strauss syndrome
C. Primary hypereosinophilic syndrome
D. Systemic lupus erythematosus
E. Wegener’s granulomatosis

Question 102

RACP 2010

Question 22:

What is the role/function of the toll like receptor

A. memory cells

B. production of immunoglobulins

C. innate immunity

D. production of immune complexes

E. t helper cells

Question 103

RACP 2010

Question 48:
A patient is undergoing chemotherapy for lymphoma. Which of these scenarios would have the highest risk of reactivation?

Question 104

RACP 2010

Question 12: (repeat from 2009)
A 52 yo man with IgA deficiency is undergoing liver transplant. What is the main issue in the peri operative period?

a) Blood transfusions
b) Immunosuppresion
c) Postoperative ventilation
d) Hepatobiliary anastomosis
e) Antibiotic selection

Question 105

RACP 2010

Question 71:

A 58 year old man is admitted for cellulitis of right leg. He states that he has a penicillin allergy. He said his mum told him that he developed a rash after taking penicillin in early childhood, but could not determine what the rash was like. The best test to determine the type of allergy to penicillin is

a) In vitro serum specific IgE to penicillin allergen
b) In vitro serum total IgE
c) Oral challenge to flucloxacillin
d) Skin prick and intradermal injection of cephazolin
e) Skin prick and intradermal injection of penicillin allergen

Question 106

RACP 2010
Question 77:

18yo male with 6-month history of recurrent swelling of both ankles and knees, all episodes resolving spontaneously. During this period of time, patient also experienced intermittent abdominal pain and diarrhea, but there is no associated temporal pattern with LL symptoms. Which investigation is most likely to yield diagnosis?

a) colonoscopy
b) HLA-B27
c) Rheumatoid factor
d) XR knee
e) Inflammatory markers

Question 107

RACP 2009a Question 9
A young person with a confirmed IgE peanut allergy causing anaphylaxis. This person is most likely
to also have allergy to
A) Chocolate ice cream.
B) Sesame seed.
C) Hazelnut.
D) Coconut.
E) Banana.

Question 108

RACP 2009a Question 30
Intravenous immunoglobulin (IV Ig) has greatest therapeutic value in:
A. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
B. Common Variable Immuno Deficiency (CVID)
C. Pemphigus Vulgaris
D. Wegnerís Granulomatosis
E. IgG Subclass deficiency

Question 109

RACP 2009 Question 70
Which cytokine stimulates the release of acute phase reactants from the liver?
a) IL-8
b) IL-12
c) IFN gamme
d) IL-6

Question 110

RACP 2009b 1 Young male with HIV presented with symptoms of malaise, lethargy.
CD4 T cell 0.02 x 10*6
HIV viral load 200,000 copies
Diagnosed with M. avium
Treated with Rifabutin, Ethambutol, Clarithromycin and constitutional symptoms
improved.
2 weeks later, he developed fever, tender left cervical lymphadenopathies. What is
the cause?
A NHL
B Immune reconstitution syndrome
C Bartonella henslae
D Toxoplasmosis
E Syphilis

Question 111

RACP 2009b Question 25
14 year old presents with swelling of lips(pic of child with upper and lower lips
swollen) abdominal pain, nausea and vomiting. There is no urticaria. Next most
appropriate investigation:
A. tryptase level
B. IgE levels against peanut
C. C3 level
D. C1 inhibitor functional assay
E. C1q level

Question 112

RACP 2008a QUESTION 3

Which of the following vaccines is contraindicated in immunosuppressed individuals?

A. Influenza.

B. Conjugated meningococcal.

C. Varicella/Zoster.

D. Conjugated pneumococcal.

E. Hepatitis A

Question 113

RACP 2008a QUESTION 14

Which of the following manifestations of natural rubber latex (NRL) sensitivity is least likely to be

associated with circulating latex-specific Immunoglobulin E (IgE)?

A. Urticaria.

B. Occupational asthma.

C. Rhinoconjunctivitis.

D. Contact dermatitis.

E. Angioedema.

Question 114

RACP 2008a QUESTION 27

Recurrent infections with which of the following organisms is most characteristic of a disorder of

neutrophil phagocytic function (such as chronic granulomatous disease)?

A. Non-tuberculous mycobacteria.

B. Pseudomonas aeruginosa.

C. Nocardia species.

D. Pneumocystis jiroveci (carinii).

E. Staphylococcus aureus.

Question 115

RACP 2008a QUESTION 48

Which of the following factors is most predictive of the development of cyclophosphamide-induced

gonadal failure in pre-menopausal females, with systemic necrotising vasculitis, who are undergoing

cyclophosphamide therapy?

A. Gonadal activity during therapy.

B. Older age.

C. Cumulative dose.

D. Pulsed intravenous cyclophosphamide delivery.

E. Concurrent therapy with MESNA.

Question 116

RACP 2008a QUESTION 53

Secretion of which of the following cytokines is most characteristic of CD4+CD25+ regulatory

T lymphocytes (Tregs) in downregulation of immune responses?

A. Interferon gamma (IFN-g).

B. Interleukin-4 (IL-4).

C. Interleukin-10 (IL-10).

D. Interferon-beta (IFN-b).

E. Granulocyte colony stimulating factor (G-CSF).

Question 117

RACP 2008b QUESTION 10

A 25-year-old female with a history of allergic rhinitis and mild atopic dermatitis is currently pregnant

with her second child. Her two-year-old son has infantile eczema and peanut allergy confirmed on

skin prick testing. The patient requests advice about dietary interventions during this pregnancy to

reduce the risk of the second child developing peanut sensitisation.

Which of the following is the most appropriate advice?

A. Avoidance of peanuts and peanut products.

B. Avoidance of all nuts.

C. Omega-3 fatty acid supplementation.

D. Elimination diet (low allergen, additive and preservative).
E. No specific dietary intervention

Question 118

RACP 2008b QUESTION 63

A 21-year-old male is referred for management of severe rhinosinusitis. He describes symptoms of

chronic nasal congestion, post-nasal drip and headache. Symptoms are acutely worse after aspirin

ingestion which also results in development of dyspnoea and wheeze. Examination reveals bilateral

nasal polyposis with nasal airway obstruction. Skin prick testing for common aeroallergens is

negative.

In addition to advising avoidance of aspirin and non-steroidal anti-inflammatory agents, which of the

following is the most appropriate first line of therapy for management of rhinosinusitis in this patient?

A. Referral for surgical polypectomy.

B. Intranasal corticosteroid spray.

C. Oral histamine-1 (H1) – blocker.

D. Aspirin desensitisation.

E. Oral montelukast.

Question 119

RACP 2008b QUESTION 84

A 15-year-old male presents with acute onset of symptoms of upper airway obstruction. He has a

history of hereditary angioneurotic oedema. Which of the following is the most effective therapy?

A. Histamine-1 (H1) blockers.

B. Intravenous glucocorticoids.

C. Fresh frozen plasma.

D. Intramuscular adrenaline.

E. C1 inhibitor concentrate.

Question 120

RACP 2007a QUESTION 11
Which of the following is the most common mechanism of a Febrile Non-Haemolytic Transfusion
reaction (FNHTR) to transfusion of packed red cells?
A. Bacterial contamination of donor product.
B. Immediate hypersensitivity to proteins of donor origin.
C. Interaction between donor antibodies with recipient granulocytes.
D. Interaction between donor granulocytes with recipient antibodies.
E. Interaction between donor red cells with recipient red cell antibodies.

Question 121

RACP 2007a QUESTION 32
Many HIV (human immunodeficiency virus) protease inhibitors are marketed in a combination that includes a small dose of ritonavir eg. Lopinavir 133mg-ritonavir 233mg. Which of the following provides the best rationale for the use of such combinations?
A. Enhancement of anti-HIV activity.
B. Improved patient compliance.
C. Improved pharmacokinetic profile.
D. Reduction of metabolic side effects.
E. Reduction in development of HIV drug resistance.

Question 122

RACP 2007a QUESTION 39
Secretion of which of the following cytokines is most characteristic of T helper cells from patients with cell-mediated immune disorders such as multiple sclerosis?
A. Interleukin - 4 (IL-4).
B. Interleukin - 10 (IL-10).
C. Interleukin - 12 (IL-12).
D. Interferon - gamma (IFN-γ).
E. Interferon - beta (IFN-β).

Question 123

RACP 2007a QUESTION 57
A novel therapeutic agent is developed which increases numbers of CD4+ CD25+ regulatory T cells. For which of the following conditions is there the most potential for benefit from treatment with this
agent?
A. Alzheimer’s disease.
B. HIV (human immunodeficiency virus) infection.
C. Idiopathic CD4 lymphopenia.
D. Hodgkin’s disease.
E. Multiple sclerosis.

Question 124

RACP 2007b Q35

A 42-year-old woman with human immunodeficiency virus (HIV) infection presents to the emergency
department with a six week history of general malaise, fever, night sweats and loss of 5kg weight. She
was born in Papua New Guinea but came to Australia five years ago. She takes zidovudine,
lamivudine and nevirapine. Her viral load is undetectable and CD4 count is 0.41 x 109/L [0.45-1.4 x109/L]. Examination is unremarkable.
Her Chest X-ray shows patchy consolidation in the left upper zone as shown below.

What is the most likely cause of the radiological changes?
A. Pneumocystis pneumonia (PCP).
B. Mycobacterium avium complex (MAC).
C. Mycobacterium tuberculosis (MTB).
D. Burkholderia pseudomallei.
E. Cytomegalovirus (CMV).

Question 125

RACP 2007b Q42

A 45-year-old male develops a blistering skin rash as shown below during treatment with co-trimoxazole. A diagnosis of drug allergy is suspected.

Which of the following is the most appropriate next step?
A. Skin testing with trimethoprim.
B. Skin testing with sulphamethoxazole.
C. Oral challenge with co-trimoxazole.
D. RAST (radioallergosorbent test) for co-trimoxazole.
E. No further investigations necessary.

Question 126

RACP 2007b QUESTION 52
A 20-year-old female presents with a one month history of malaise, nausea, abdominal pain, itch and
polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals
jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute
hepatocellular injury, with a polyclonal increase in IgG (immunoglobulin G) of 32g/L (6.1-15.5).
Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver biopsy are of a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes and eosinophils consistent with an autoimmune hepatitis.
Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical response to therapy?
A. Anti-nuclear antibody.
B. Anti-smooth muscle antibody (F-actin–specific).
C. Anti-mitochondrial antibody.
D. Anti-liver-kidney microsomal antibody.
E. Atypical perinuclear anti-neutrophil cytoplasmic antibody.

Question 127

RACP 2007b QUESTION 55
A 45-year-old human immunodeficiency virus-1 (HIV-1)-infected male who has been followed without
anti-retroviral therapy for 12 months is referred for assessment and further management. He has no HIV-related symptoms or signs. Baseline evaluation and counselling is performed.
Which of the following findings provides the strongest indication to initiate anti-retroviral therapy immediately?
A. CD4 cell count 300 per cubic millimeter.
B. Plasma HIV-1 viral load 100,000 copies/mL.
C. Decline of CD4 cell count from 350 to 300 per cubic millimetre over 12 months.
D. Evidence of drug-resistant HIV variants in HIV genotyping.
E. Active hepatitis C infection on serologic testing.

Question 128

RACP 2006a QUESTION 10

Which of the following cells is most important in the pathogenesis of vasculitis in temporal arteritis?

A. Multinucleate giant cell.

B. Macrophage.

C. CD8+ T cell.

D. CD4+ T cell.

E. Dendritic cell.

Question 129

RACP 2006a QUESTION 15

A defect in elimination of which of the following is most likely to occur post-splenectomy?

A. Polysaccharide antigens.

B. T cell-dependent antigens.

C. Intracellular microbes.

D. Protein antigens.

E. Staphylococcus aureus

Question 130

RACP 2006a QUESTION 26

Which of the following best describes the toxicological mechanism of recurrent acute angioedema related to the use of angiotensin converting enzyme (ACE) inhibitors?

A. IgE (immunoglobulin E) mediated hypersensitivity.

B. Delayed-type hypersensitivity.

C. Enhancement of complement activation.

D. Disruption of endothelial tight junctions.

E. Impairment of bradykinin catabolism

Question 131

RACP 2006a QUESTION 35

Defects in the terminal attack elements of the complement system (C6, C7, C8) are most strongly associated with an increased risk of infection with which of the following pathogens?

A. Streptococcus pneumoniae.

B. Neisseria meningitidis.

C. Pneumocystis jiroveci.

D. Listeria monocytogenes.

E. Haemophilus influenzae.

Question 132

RACP 2006a QUESTION 45

In which of the following does mannose binding lectin (MBL) have the most significant role?

A. Carbohydrate metabolism.

B. Fat metabolism.

C. Innate immunity.

D. Cardiovascular homeostasis.

E. Adaptive immunity.

Question 133

RACP 2006b QUESTION 15

A 52-year-old woman presents with dry eyes which have progressively worsened over the past three years. On examination her Schirmer test is 1mm in 5 minutes [5mm in 5 minutes] and she has positive Rose Bengal staining of both corneas. Her erythrocyte sedimentation rate is 98 mm/hr [<21mm/hr], antinuclear antibody is positive with a speckled pattern and a titre of 1:640 and Anti-Ro and –La antibodies are detected.

The most appropriate initial treatment is:

A. hydroxychloroquine.

B. low dose oral prednisolone.

C. methotrexate.

D. hypomellose tear substitute.

E. prednisolone eye drops.

Question 134

RACP 2006b QUESTION 22

A 25-year-old female presents with recurrent facial angioedema. The following laboratory results are obtained:

Complement C3 0.36 g/L 0.79-1.80]

Complement C4 0.06 g/L [0.13-0.48]

Total haemolytic complement (CH100) 210 CH100 units [390-1015]

Which of the following is the most likely explanation for these findings?

A. Hereditary C1 (complement 1) inhibitor deficiency.

B. Delayed transfer of serum to laboratory.

C. C4 null allele.

D. Acquired C1 inhibitor deficiency.

E. ACE-inhibitor therapy

Question 135

RACP 2006b QUESTION 26

A 28-year-old woman presents with episodes of colour change in her distal fingers when they are exposed to the cold. The episodes occur most days and are characterised by white numb finger tips which become blue and then red. She describes similar episodes that have occurred for many years. She is otherwise well. Examination is unremarkable. Investigations show a positive anti-nuclear antibody of a speckled pattern with a titre of 1:80. The most likely diagnosis is:

A. limited scleroderma.

B. diffuse scleroderma.

C. primary Raynaud’s phenomenon.

D. systemic lupus erythematosus.

E. carcinoid syndrome.

Question 136

RACP 2006b QUESTION 42

A patient is at high risk for repeat radiographic contrast media reactions. Which of the following is least likely to be effective?

A. Desensitisation with contrast media.

B. Change to use of non-ionic contrast media.

C. Premedication with oral diphenhydramine.

D. Premedication with oral prednis(ol)one.

E. Premedication with intramuscular adrenaline.

Question 137

RACP 2006 b QUESTION 70

A 21-year-old female presents with anaphylactic shock. Her blood pressure initially responds to a dose of adrenaline however it falls again 30 minutes later. What would be the most important next intervention?

A. Subcutaneous adrenaline.

B. Intramuscular adrenaline.

C. Intravenous fluid challenge.

D. Histamine 1 and 2 receptor antagonists.

E. Intravenous corticosteroid.

Question 138

RACP 2006a QUESTION 98

Skin prick testing for specific IgE (immunoglobulin E) is most appropriate for investigation of which of the following conditions?

A. Severe systemic reaction to gadolinium-based contrast medium.

B. Chronic urticaria.

C. Acute urticaria/angioedema following aspirin administration.

D. Large local reaction to bee sting.

E. Anaphylaxis following peanut ingestion.

Question 139

RACP 2005a QUESTION 31

Which one of the following cells of the immune system is most reliant on its release of mediators into the extracellular fluid surrounding the organism in order to carry out its role in eradication of foreign organisms?

A. Neutrophils.

B. Eosinophils.

C. Macrophages.

D. Cytotoxic T lymphocytes.

E. Natural killer cells.

Question 140

RACP 2005a QUESTION 44

Which of the following most accurately reflects the mechanism of complement consumption induced by complement component 3 (C3) nephritic factors?

A. Activation of the classical complement pathway.

B. Stabilisation of the membrane attack complex, C5-9.

C. Amplification of C3 “tickover”.

D. Stabilisation of the C3 convertase, C3bBb.

E. Inhibition of the complement regulator, Factor I.

Question 141

RCAP 2004a QUESTION 9

Diagnosis of a number of autoimmune diseases involves the detection of serum autoantibodies. Which of the following criteria is most indicative of a pathogenic role for a disease-associated autoantibody?

A. Demonstration of immunoglobulin at site of lesion.

B. Elution of immune complexes from site of lesion.

C. Reproduction of disease by passive transfer of patient immunoglobulin.

D. Clinical response to plasmapheresis.

E. Elution of complement from site of lesion.

Question 142

RACP 2004a QUESTION 38

Urticaria, wheezing and hypotension may occur with each of the following agents. Which of the following is most likely to have an immunoglobulin E (IgE)-mediated mechanism underlying this reaction?

A. Radiographic contrast medium.

B. Captopril.

C. Acetylcysteine.

D. Vancomycin.

E. Penicillin.

Question 143

RACP 2004a QUESTION 54

The cell population most responsible for driving the pathogenesis of sarcoidosis is:

A. macrophage.

B. fibroblast.

C. B lymphocyte.

D. type 1 helper T lymphocyte (Th1 cell).

E. type 2 helper T lymphocyte (Th2 cell).

Question 144

RACP 2004a QUESTION 69

Which one of the following most differentiates between antigen-dependent and antigen-independent B cell development?

A. B cell surface expression of surrogate light chain.

B. B cell surface expression of μ heavy chain.

C. B cell surface expression of CD79a (immunoglobulin α (Ig-α)).

D. Immunoglobulin gene rearrangement.

E. Somatic hypermutation.

Question 145

RACP 2004b QUESTION 13

A 21-year-old woman presents with a two-year history of colour changes in her hands from white to blue to pink following exposure to cold.

Which of the following laboratory results would indicate the highest risk of future development of a Raynaud’s phenomenon-associated secondary disease?

A. Mild anaemia.

B. Elevated C-reactive protein (CRP).

C. Positive rheumatoid factor.

D. Positive speckled pattern antinuclear antibody test (ANA).

E. Positive anticentromere antibody test.

Question 146

RACP 2004b
QUESTION 41

An 87-year-old man presents with extensive intact blisters over his trunk and all limbs but with sparing of his face and mucous membranes. Direct immunofluorescence on biopsy of perilesional skin shows a linear deposition of immunoglobulin G (IgG) and complement component 3 (C3) at the dermal-epidermal junction.

Which of the following would be the most appropriate initial treatment?

A. Azathioprine 2 mg/kg/day.

B. Oral prednis(ol)one 2 mg/kg/day.

C. Topical high-potency corticosteroids.

D. Plasmapheresis, five times over two weeks.

E. Intravenous cyclophosphamide 0.7 g/m2 body surface area.

Question 147

RACP 2004b QUESTION 59

Therapeutic blockade of alpha 4 (α4) integrins is currently under clinical trial for several diseases. On the basis of known pathogenesis, patients with which one of the following conditions are most likely to receive benefit from this treatment?

A. Migraine.

B. Stroke.

C. Multiple sclerosis.

D. Alzheimer’s disease.

E. Epilepsy.

Question 148

RACP 2004b QUESTION 86

A previously well 58-year-old woman presents with a two-year history of marked sicca symptoms, intermittent bilateral parotid swelling and an abnormal Schirmer’s test. Investigations reveal a positive antinuclear antibody (ANA) test (titre >1:2560), speckled pattern with positive Ro (Sjögren’s syndrome A (SS-A)) and La (Sjögren’s syndrome B (SS-B)) antibody tests and negative anti-DNA antibodies. Rheumatoid factor is strongly positive and marked polyclonal gammopathy is noted on serum protein electrophoresis (EPG). Full blood count is normal. Serum biochemistry is normal except for a serum bicarbonate of 15 mmol/L [24-31].

In the long-term follow-up, which of the following features is least likely to occur?

A. Glomerulonephritis.

B. Raynaud’s phenomenon.

C. Arthritis.

D. Nephrocalcinosis.

E. Lymphoma.

Question 149

RACP 2004b QUESTION 94

A 45-year-old woman is referred following relocation from interstate. Her accompanying medical records list her major diagnosis as systemic lupus erythematosus (SLE). You elicit a history of three to four years of polyarthritis, Raynaud’s phenomenon, myalgia and proximal muscular weakness and recently, increasing shortness of breath on exertion. Examination reveals a blood pressure of 120/70 mmHg, a single prominent second heart sound, diffuse puffiness of the digits, mild proximal weakness and mild synovitis of the wrists and small joints of the hands.

Which of the following would be the most likely cause of death in this woman?

A. Diffuse proliferative glomerulonephritis.

B. Myocarditis.

C. Renovascular hypertension.

D. Pulmonary hypertension.

E. Cerebral vasculitis.

Question 150

RACP 2003a QUESTION 4

Which one of the following cell surface molecules is least important in the regulation of natural killer (NK) cell function?

A. Major histocompatibility complex (MHC) class I on the target cell.

B. MHC class II on the target cell.

C. Killer-activating receptors on the NK cell.

D. Killer-inhibiting receptors on the NK cell.

E. Receptor for the Fc portion of immunoglobulin G (IgG) on the NK cell.

Question 151

RACP 2003a QUESTION 9

Tumours of the immune system developing in patients with immune dysregulation due to immune deficiency (including human immunodeficiency virus (HIV) infection) and autoimmune disease are most likely to arise from which cell lineage?

A. B cell.

B. CD4 positive (CD4+) helper T cell.

C. CD8 positive (CD8+) cytotoxic T cell.

D. Monocyte.

E. Thymocyte.

Question 152

RACP 2003a QUESTION 13

The cell population most responsible for driving the pathogenesis of sarcoidosis is:

A. macrophage.

B. fibroblast.

C. B lymphocyte.

D. type 1 helper T lymphocyte (Th1 cell).

E. type 2 helper T lymphocyte (Th2 cell).

Question 153

RACP 2003a QUESTION 40

In which one of the following disease states is superantigen stimulation of T cells the predominant pathogenic process?

A. Endotoxic shock.

B. Stevens-Johnson syndrome.

C. Staphylococcal toxic shock.

D. Anaphylactoid reaction to intravenous radio-contrast medium.

E. Guillain-Barré syndrome.

Question 154

RACP 2003b QUESTION 94

A 10-year-old boy suffers an acute anaphylactic reaction following ingestion of peanuts. His skin test to peanut is strongly positive and he develops diffuse urticaria 10 minutes after the skin test is applied.

In addition to education in the use of a self-injecting adrenaline kit, the most appropriate management is:

A. peanut desensitisation.

B. daily antihistamines until his allergy declines with age.

C. lifelong avoidance of peanuts.

D. leukotriene inhibitor therapy.

E. provision of antihistamines for future attacks.

Question 155

RACP 2002a QUESTION 8

With respect to the immunological mechanisms involved in effective immunotherapy against bee venom (with increasing concentrations of purified venom allergen), which one of the following is least likely to occur?

A. Decreased production of type 2 helper T cell lymphocyte (Th2)-type cytokines.

B. Increased production of type 1 helper T cell lymphocyte (Th1)-type cytokines, interleukin 12 (IL-12) and interferon gamma (INFγ).

C. Increased production of interleukin 10 (IL-10).

D. Elimination of allergen specific B cell clones.

E. Production of immunoglobulin G (IgG) class blocking antibodies.

Question 156

RACP 2002a QUESTION 23

Which one of the following cell surface molecules is least important in the regulation of natural killer (NK) cell function?

A. Major histocompatibility complex (MHC) class I on the target cell.

B. MHC class II on the target cell.

C. Killer-activating receptors on the NK cell.

D. Killer-inhibiting receptors on the NK cell.

E. Receptor for the Fc portion of immunoglobulin G (IgG) on the NK cell.

Question 157

RACP 2002a QUESTION 37

T lymphocytes expressing both CD4 and CD8 on the cell surface are most likely to be found in which one of the following anatomical locations in healthy individuals?

A. Bone marrow.

B. Thymus.

C. Peripheral blood.

D. Lymph nodes.

E. Spleen.

Question 158

RACP 2002a QUESTION 38

The immunological mechanism most responsible for the development of tuberculoid leprosy rather than lepromatous leprosy is:

A. immune complex formation.

B. complement activation.

C. specific antibody production.

D. cell-mediated immunity.

E. natural killer cell activation.

Question 159

RACP 2002a QUESTION 48

The COX-2 isoform of cyclo-oxygenase is most strongly expressed in which one of the following tissues?

A. Platelets.

B. Established scar tissue.

C. Synovium from osteoarthritic joint.

D. Gastric mucosa.

E. Rheumatoid synovium.

Question 160

RACP 2002a QUESTION 49

Which one of the following biological events is least important in the role played by Langerhans (dendritic) cells in the afferent arm of the immune response to infections in the skin?

A. Activation following the binding of microbial polysaccharides to the Langerhans cell.

B. Migration of the Langerhans cell to the draining lymph node.

C. Up-regulation of the major histocompatibility complex (MHC) class I molecules on the Langerhans cell.

D. Up-regulation of the MHC class II molecules on the Langerhans cell.

E. Up-regulation of the co-stimulatory molecules on the Langerhans cell.

Question 161

RACP 2002a QUESTION 62

Which one of the following cells of the immune system is most reliant on its release of mediators into the extracellular fluid surrounding the organism in order to carry out its role in eradication of foreign organisms?

A. Neutrophils.

B. Eosinophils.

C. Macrophages.

D. Cytotoxic T lymphocytes.

E. Natural killer cells.

Question 162

RACP 2001a Question 7

Graft-versus-host disease is a major complication of allogeneic stem cell transplantation for haematological malignancy in adults.

Which one of the following has the least influence on the risk of developing graft-versus-host disease?

A. Age of recipient.

B. Donor-recipient ABO blood group incompatibility.

C. In vitro T cell depletion of the graft.

D. Type of HLA-matched donor (sibling versus unrelated).

E. Donor-recipient HLA mismatch.

Question 163

RACP 2001a Question 8

Dendritic cells are distinguished by an exceptional ability to carry out which one of the following immune functions?

A. Phagocytosis.

B. Cytokine secretion.

C. Chemokine secretion.

D. Immunoglobulin secretion.

E. Antigen presentation.

Question 164

RACP 2001a Question 16

The COX-2 isoform of cyclo-oxygenase is most strongly expressed in which one of the following tissues?

A. Platelets.

B. Established scar tissue.

C. Synovium from osteoarthritic joint.

D. Gastric mucosa.

E. Rheumatoid synovium.

Question 165

RACP 2001a Question 21

T lymphocytes expressing both CD4 and CD8 on the cell surface are most likely to be found in which one of the following anatomical locations in healthy individuals?

A. Bone marrow.

B. Thymus.

C. Peripheral blood.

D. Lymph nodes.

E. Spleen.

Question 166

RACP 2001a Question 33

In renal transplant biopsies, which one of the following features of acute rejection has the worst prognostic implication?

A. Glomerular T cell infiltrate.

B. Dense interstitial mononuclear infiltrate.

C. Increased expression of HLA-DR on graft cells.

D. Vascular injury.

E. Tubulitis due to CD8+ T cells.

Question 167

RACP 2001a Question 34

Which one of the following biologically active components of the complement cascade is most directly responsible for the formation of transmembrane channels leading to cell lysis?

A. C3a.

B. C3b.

C. C4a.

D. C5a.

E. C5-9.

Question 168

RACP 2001a Question 49

At the onset of infection or inflammation, the level of which one of the following acute phase proteins rises most rapidly and by the highest percentage over background?

A. Fibrinogen.

B. Haptoglobin.

C. Transferrin.

D. C-reactive protein.

E. Complement component 3 (C3).

Question 169

RACP 2001a Question 53

Cytokine regulation (especially involving interleukin 2) is least affected by which one of the following immunosuppressive drugs?

A. Prednis(ol)one.

B. Mycophenolate.

C. Cyclosporin.

D. Tacrolimus (FK506).

E. Rapamycin.

Question 170

RACP 2001b Question 54

A 27-year-old woman presents with an allergic reaction to a bee sting. Which one of the following clinical features, listed in order of severity, would be the minimum requirement sufficient to advise bee venom immunotherapy?

A. Large local reaction.

B. Localised urticaria.

C. Generalised urticaria.

D. Distant angio-oedema.

E. Anaphylaxis.

Question 171

RACP 2001b Question 68

Which one of the following is the most common cause of initial-onset of angio-oedema in patients over the age of 60?

A. Food allergy.

B. Hereditary angio-oedema.

C. Acquired C1 inhibitor deficiency.

D. Penicillin allergy.

E. Angiotensin-converting enzyme (ACE) inhibitor therapy.

Question 172

RACP 2001b A 42-year-old woman with diffuse proliferative glomerulonephritis secondary to systemic lupus erythematosus (SLE) presents with the rash shown in the two photographs below, three months after commencement of therapy with high dose prednis(ol)one, 1 mg/kg/day and cyclophosphamide, 1 g/m2/month by intravenous administration.

Reduced function of which one of the following immunological effector mechanisms is likely to be the main contributor to the severity of the rash?

A. Complement.

B. Neutrophils.

C. Specific antibody.

D. Natural killer (NK) cells.

E. Specific cell-mediated immunity.

Question 173

RACP 2000a Question 11

A T lymphocyte encountering its specific antigen in the absence of a co-stimulatory signal via CD28 is least likely to:

A. undergo apoptosis (programmed cell death).

B. become anergic (unresponsive to appropriate stimulation).

C. proliferate.

D. produce low levels of helper T cell type 1 (Th1) cytokines.

E. produce low levels of helper T cell type 2 (Th2) cytokines.

Question 174

RACP 2000a Question 21

Failure of signalling through the interleukin 7 receptor (IL-7 R), due to inherited deficiency of either the common interleukin receptor γ chain (γc) or Janus kinase 3 (JAK3 protein kinase), produces a severe combined immune deficiency (SCID) state, the features of which are best explained by the loss of expansion of which one of the following cell types?

A. Type 1 helper T lymphocytes (Th1 cells).

B. Type 2 helper T lymphocytes (Th2 cells).

C. B lymphocytes.

D. Natural killer (NK) cells.

E. Lymphoid progenitor cells.

Question 175

RACP 2000a Question 29

The large granular lymphocytes observed in the early cellular response to virus infected cells are most likely to be:

A. B lymphocytes.

B. naive T lymphocytes.

C. memory CD4+ T lymphocytes.

D. memory CD8+ T lymphocytes.

E. natural killer (NK) cells.

Question 176

RACP 2000a Question 35

Cytokine regulation (especially involving interleukin 2) is least affected by which one of the following immunosuppressive drugs?

A. Prednis(ol)one.

B. Mycophenolate.

C. Cyclosporin.

D. Tacrolimus (FK506).

E. Rapamycin.

Question 177

RACP 2000a Question 41

Which one of the following bone marrow cell populations has the highest proportion of its cells in active cell cycle?

A. Pluripotential stem cell.

B. Myeloblast.

C. Myelocyte.

D. Metamyelocyte.

E. Reserve granulocyte pool.

Question 178

RACP 2000 a Question 44

A type 2 helper T lymphocyte (Th2 cell) differs most from a type 1 helper T lymphocyte (Th1 cell) in which one of the following?

A. Surface expression of CD4.

B. Surface expression of major histocompatibility gene complex (MHC) class II.

C. Production of interleukin 3 (IL-3).

D. Production of interleukin 5 (IL-5).

E. Responsiveness to antigen presented by macrophages.

Question 179

RACP 2000a Question 55

Which one of the following effects of the complement system is least important in the control of infection with gram-positive pyogenic bacteria?

A. Opsonisation by direct binding of complement to the bacteria.

B. Opsonisation via complement binding to antibody-coated bacteria.

C. Anaphylatoxic activity of C3a and C5a.

D. Chemotactic activity of C3a and C5a.

E. Lysis of the bacterial membranes by the complement membrane attack complex (C5b-C9).

Question 180

RACP 2000a Question 62

The low affinity antibodies produced following stimulation of B lymphocytes by a thymus independent antigen, such as pneumococcal polysaccharide, belong predominantly to which one of the following immunoglobulin classes/subclasses?

A. IgA.

B. IgG1.

C. IgG3.

D. IgM.

E. IgE.

Question 181

RACP 2000b Question 3

A 39-year-old woman presented with the development over two weeks of the lesions shown in photograph A (see following page).

Direct immunofluorescence performed on a biopsy of the skin adjacent to the lesions revealed the changes shown in photograph B (see following page) which has been stained for complement component 3 (C3).

Which one of the following is most likely to be responsible for the immunopathogenesis of the lesions shown in photograph A?

A. Immunoglobulins.

B. CD4+ T lymphocytes.

C. CD8+ T lymphocytes.

D. Monocytes.

E. Mast cells

Question 182

RACP 2000b Question 23

A 32-year-old woman with mitral valve disease was given an injection of penicillin immediately prior to a general anaesthetic for extraction of impacted wisdom teeth. She developed hypotension and exhibited difficulty with ventilation.

Immediately following resuscitation, which one of the following tests would be most helpful to confirm a diagnosis of anaphylaxis?

A. Penicillin radioallergosorbent test (RAST).

B. Skin testing for the anaesthetic agents used.

C. Serum tryptase.

D. Complement component (C1) inhibitor level.

E. Serum histamine.

Question 183

RACP 1999a Question 10

Cytokine regulation (especially involving interleukin 2) is least affected by which one of the following immunosuppressive drugs?

A. Prednis(ol)one.

B. Mycophenolate.

C. Cyclosporin.

D. Tacrolimus (FK506).

E. Rapamycin.

Question 184

RACP 1999b Question 12

The antigen to which the auto-antibody pANCA (perinuclear anti-neutrophil cytoplasmic antibody) most commonly binds in neutrophil azurophilic granules is:

A. myeloperoxidase.

B. tumour necrosis factor α.

C. elastase.

D. proteinase 3.

E. cathepsin G.

Question 185

RACP 1999a Question 15

A type 2 helper T lymphocyte (Th2 cell) differs most from a type 1 helper T lymphocyte (Th1 cell) in which one of the following?

A. Surface expression of CD4.

B. Surface expression of major histocompatibility gene complex (MHC) class II.

C. Production of interleukin 3 (IL-3).

D. Production of interleukin 5 (IL-5).

E. Responsiveness to antigen presented by macrophages.

Question 186

RACP 1999a Question 43

Memory T lymphocytes differ most from naive T lymphocytes with respect to:

A. the cytokines they produce.

B. cell surface expression of CD45Ro.

C. cell surface expression of adhesion molecules.

D. cell surface expression of MHC class II.

E. their response to alloantigens.

Question 187

RACP 1999a Question 49

The large granular lymphocytes observed in the early cellular response to virus infected cells are most likely to be:

A. B lymphocytes.

B. naive T lymphocytes.

C. memory CD4+ T lymphocytes.

D. memory CD8+ T lymphocytes.

E. natural killer (NK) cells.

Question 188

RACP 1999b Question 54

Collaboration involving physical contact between B cells and T cells is essential for the activation of B cells and immunoglobulin class switching. Contact occurs between CD40 on the surface of the B cell and the CD40 ligand on activated T cells.

In which one of the following is CD40 ligand binding most likely to be defective?

A. Selective IgA deficiency.

B. Severe combined immunodeficiency.

C. X-linked agammaglobulinaemia.

D. Wiskott-Aldrich syndrome.

E. X-linked hyper IgM syndrome.