Rheumatoid arthritis

• Understand pathogenesis and epidemiology of RA
• List sites typical affected and characteristics of specific anatomic locations
• Describe specific autoimmune mechanisms responsible for clinical manifestations
• Become familiar with different types of clinical presentation
• Differentiate between RA and osteoarthritis
• Understand pathophysiology of osteoarthritis and typical joints affected by this process
• Describe diagnostic modalities utilized in making the diagnosis of RA
• Understand frequency of serum markers potentially present in patients with RA
• Describe several treatment modalities for RA and relative effectiveness of each



Joints. RA typically manifests as a symmetric arthritis principally affecting the small joints of the hand and feet. The synovium becomes grossly edematous, thickened, and hyperplastic, transforming its smooth contour to one covered by delicate and bulbous villi ( Fig. 26-43 A, B ). The characteristic histologic features include (1) synovial cell hyperplasia and proliferation; (2) dense inflammatory infiltrates (frequently forming lymphoid follicles) of CD4+ helper T cells, B cells, plasma cells, dendritic cells, and macrophages ( Fig. 26-43 C ); (3) increased vascularity due to angiogenesis; (4) fibrinopurulent exudate on the synovial and joint surfaces; (5) osteoclastic activity in underlying bone, allowing the synovium to penetrate into the bone and cause periarticular erosions and subchondral cysts. Together, the above changes produce a pannus: a mass of edematous synovium, inflammatory cells, granulation tissue, and fibroblasts that grows over the articular cartilage and causes its erosion. In time, after the cartilage has been destroyed, the pannus bridges the apposing bones to form a fibrous ankylosis , which eventually ossifies and results in fusion of the bones, called bony ankylosis ( Fig. 26-41 ).




1. Which of the following is not a criterion for
remission in rheumatoid arthritis (RA) according
to the ACR/EULAR 2011 criteria?
a. C-reactive protein (CRP) ≤1 mg/dL
b. Swollen joint count ≤1
c. Tender joint count ≤1
d. Physician global assessment ≤1

2. A 45-year-old female complaints of increasing
widespread joint pains which are worse in the
evening after a stressful day at work. She describes
puffy hands and feet and a painful neck. Her
concentration is very poor and she has recently
suffered from marital problems. Rheumatoid factor
is mildly positive. Examination reveals an increased
body mass index and global restriction of movement
due to pain, but no synovitis. Which of the following
investigations would be useful in this case?
a. Anti-cyclic citrullinated peptide antibody
b. Ultrasound scan hands and feet
c. Anti-JO-I antibody
d. Erythrocyte sedimentation rate and C reactive
e. Anti-mitochondrial antibody

3. Which of the following drugs is most likely to
cause systemic lupus-like syndrome?
a. Baclofen
b. Isoniazid
c. Methotrexate
d. Procainamide
e. Sulfasalazine

4. A 25-year-old female gives birth to a baby with
complete heart block who subsequently requires
pacemaker insertion. Which of the following
antibodies is most likely to be detected in the
maternal serum?
a. Anti-double-stranded deoxyribonucleic acid
(dsDNA) antibodies
b. Anti-endomysial antibodies
c. Anti-Ro/SSA antibodies
d. Anti-SCL70 antibodies
e. Rheumatoid factor

5. Which of the following is a pro-inflammatory
a. CRP
b. Interleukin 4 (IL-4)
c. IL-10
d. Serum amyloid precursor protein
e. Tumour necrosis factor-alpha

6. A 72-year-old man presents with an acutely painful
right knee. On examination, he had a temperature
of 37°C with a hot, swollen right knee. Of relevance
amongst his investigations, was his white cell count
which was 12.6 × 109
/l and a knee X-ray revealed
reduced joint space and calcification of the articular
cartilage. Culture of aspirated fluid revealed no growth.
What is the most likely diagnosis?
a. Gout
b. Psoriatic monoarthropathy
c. Pseudogout
d. Rheumatoid arthiritis
e. Septic arthritis

7. Which of the following regarding Infliximab is
most true?
a. Is a monoclonal antibody to the glycoprotein
IIb-IIIa receptor
b. Is authorized for the treatment of severe
ulcerative colitis
c. Is licensed for the treatment of RA
d. It prevents relapse of Crohn’s disease in patients
who are in remission
e. Must not be used in combination with
methotrexate due to increased toxicity

8. A 25-year-old lady with known systemic lupus erythematosus (SLE) presents with the nephrotic syndrome. A renal biopsy is performed and this confirms diffuse proliferative glomeronephritis (WHO Class IV). Which of the following treatment regimens would you advise? a. Azathioprine alone b. Prednisolone alone c. Azathioprine and prednisolone d. Prednisolone and intravenous cyclophosphamide e. Prednisolone and methotrexate

9. Which of the following auto-antibodies may have a
role in monitoring disease activity?
a. Rheumatoid factor in RA
b. Antinuclear antibodies in SLE
c. Anti-Sm antibodies in SLE
d. Anti-dsDNA antibodies in SLE
e. Anti-Ro (SSA) antibodies in Sjogren’s

10. A 69-year-old woman taking hydralazine for
hypertension presents with joint pain and chest
pain. On cardiac examination, the patient has a
pericardial rub. What is the diagnosis?
a. Dermatomyositis
b. SLE
c. Polymyalgia rheumatic
d. Felty syndrome


Which of the following is the most specific test for Rheumatoid arthritis
a) Anti CCP antibody
b) Anti lgM antibody
c) Anti IgA antibody
d) Anti IgG antibody

More MCQs


Rheumatoid Arthritis is in and of itself a risk factor for osteoporosis.
All rheumatoid arthritis patients should have a bone density study to screen for osteoporosis.

Rituxan is a tumor necrosis factor inhibiting drug

  1. True
  2. False
    Rituxan depletes B cells

Every Rheumatoid Arthritis patient should be on Methotrexate

  1. True
  2. False
    Question 3 of 10
Question 8

Your score: 21

There are many patients who do well with less potent drugs such as sulfasalazine or Plaquenil. Hopefully, some day there will be a test to tell us who will have severe disease and needs early aggressive treatment now, as opposed to later.

Untreated Rheumatoid Arthritis lowers the life span.

  1. True
  2. False
Question 7

Your score: 31

Even factoring in those patients who suffer adverse drug events, those patient who are not adequately treated for their rheumatoid arthritis do not live as long, statistically speaking, as their “normal” counterparts.

Sjogren’s syndrome can occur in Rheumatoid Arthritis patients.

  1. True
  2. False
Question 6

Your score: 41

Correct! It is important to ask a patient about dry eyes or dry mouth or dry vagina, and treat these things accordingly to improve the patient’s quality of life.

Lower education level in general results in a worse outcome in Rheumatoid Arthritis.

  1. True
  2. False
Question 5


Keeping all other things equal, such as compliance with prescribed medications, less education appears to result in more debility and more severe disease.

Rheumatoid Arthritis is not associated with stiffness.

  1. True
  2. False
Question 4

Correct! One of the hallmarks of Rheumatoid Arthritis involves morning stiff of at least 45 minutes in duration.

Rheumatoid Factor is associated with more aggressive disease.

  1. True
  2. False
Question 3

Correct! A positive rheumatoid factor is associated with more destructive arthritis, as well as other manifestations besides arthritis, such as rheumatoid lung, rheumatoid nodules, etc..

Rheumatoid Arthritis affects the lumbar spine.

  1. True
  2. False
Question 2

FALSE! It can affect the cervical spine, which in fact can result in paralysis due to C1-C2 subluxation with resultant spinal cord damage.

Rheumatoid arthritis affects 10 percent of the world’s population

  1. True
  2. False
Question 1


Rheumatoid Arthritis affects 1% of the population.Rheumatoid Arthritis can occur at any age, but it usually occurs between the ages of 25-55 and is more likely to affect women than men.


■ When the response to methotrexate or other DMARDs has been inadequate, all
of the following drugs may be considered for RA except:

1. leflunomide
2. cytokine modulators (adalimumab , etanercept , infliximab)
3. Metozolv
4. ciclosporin

■ T or F:

Two examples of glucocorticoids used to treat RA are
azathioprine and ciclosporin

■ T or F:
DMARDs are considered to be first-line drugs, as their clinical effects are
relatively fast (1-2 weeks).

■ T or F:
Methotrexate is a folic acid agonist with cytotoxic and immunosuppresant activity
■ Degradative enzymes including Metalloproteinases and serine proteases, digest extracellular matrix and destroy the joint surface. In addition, the ______ has been incriminated as a major factor underlying bone erosion in RA.

1. osteoblast
2. osteoclast

■ In reactive arthritis, an infectious agent in the gastrointestinal tract incites an inflammatory reaction in individuals carrying:

1. HLA-B27
2. HLA- DR4
3. PRRs

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