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?
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
a. Anti-double-stranded deoxyribonucleic acid
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
b. Interleukin 4 (IL-4)
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?
b. Psoriatic monoarthropathy
d. Rheumatoid arthiritis
e. Septic arthritis
7. Which of the following regarding Infliximab is
a. Is a monoclonal antibody to the glycoprotein
b. Is authorized for the treatment of severe
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?
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
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
Rituxan depletes B cells
– General clinical presentation
Fragile bones, lead to fracture, blue sclera, hearing loss, poor wound healing = Osteogenesis imperfecta
– Fractures, vertebral body, HIP WRIST- Osteoporosis
– Articular pain with movement, gets worse during the day, Bouchard Nodes (proximal). Heberden Nodes (distal IP joints), interphalangial bony enlargements = osteoarthritis
– Autosomal Dominant mutation, abnormal elastin fibers, effects cardiac, occular, and skeletal systems, gene for Fibrillin 1 = Marfan’s syndrome (not Ehlers-Danlos syndrome) (remember that the elastin is wavy and abnormal, cytokines not properly signaling TGF Beta)
Key word for Ehlers Danlos syndrome = Loose joints, folding people, hypermobility, frail skin, cigarette paper thin scar, skin..onion skin thin…One type can cause empty organs to burst, arteries, uterus, danger in pregnancy – this is the vascular form.
– Lab tests
– ESR Erythrocyte sedimentation rate tells us what? = systemic inflammation
along with CRP…diseases where you could use an ESR – Rheumatoid arthritis, osteoid arthritis, middle-aged female patient (more prone to autoimmune diseases) with swelling in proximal phalangeal joint
– what test for RA? = Anti CCP cyclic citrullinated peptide (CCP) , marker for RA
– Test for CK, creatine kinase, maker for = muscle injury
If high, Pathognomonic for DMD (But CK is not specific for DMD)
– Can you always detect DMD with PCR test? No, need a muscle biopsy.
30% of the time, the PCR is not correct.
– CK isoenzyme CKMB (myocardial bound), marker for cardiac injury
– CRP (C-reactive protein) is direct marker for = inflammation (non specific), higher risk for heart attack and stroke
– ANA test – anti nuclear antibody = non-specific, can be high in several autoimmune diseases. Can be falsely positive in 5 to 10 % of pts.
– RF Rheumatoid factor, non-specific, positive for other autoimmune diseases too
– Alkaline phosphatase = one form is in the liver, marker for BONE TURNOVER, seen in children and pregnant women
– Serum calcium = what would a doc look at serum calcium? It will tell you about calcium homeostasis.
– Bisphoshanates (-dronates), when used? = used for ospetoporosis, and DMD (B/C at risk for osteoporosis) Bisphosphonaes can also be used for METASTATIC BONE DISEASE and HYOCALCEMIA
MOA = bind to bone, inhibit octeoclast mediated bone resorption.
Side effects = GI, ulcers, bone pain, OSTEONECROSIS OF JAW
– Osteoporosis and CALCITONIN