Rheumatoid Arthritis Quiz

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Questions and Answers

Which genetic allele is found in 70% of the rheumatoid arthritis population?

HLA-DRB1 (correct)

PAD14

CD4+

TNF-alpha

What role does the PAD14 allele play in the context of rheumatoid arthritis?

It produces peptidyl arginine deiminase type IV. (correct)

It stimulates synovial fibroblast activation.

It is responsible for T cell maturation.

It is a common infectious antigen.

Which signaling pathway is involved in the activation of CD4+ T cells?

NF-kB pathway

JAK-STAT pathway

CD28-CD80/86 pathway (correct)

Wnt signaling pathway

What is the role of TH1 cells in the immune response?

Produce TNF-alpha Signup and view all the answers

What is one likely consequence of synovial T cell activation in rheumatoid arthritis?

Enhanced immune response to specific peptides Signup and view all the answers

What type of antigens can act as environmental insults in rheumatoid arthritis?

Infectious antigens Signup and view all the answers

Which cytokine is primarily produced by TH17 cells?

IL-17 Signup and view all the answers

In the context of inflammation and RA, how does TNF-alpha mainly function?

Activates osteoclasts to erode bone Signup and view all the answers

What is Caplan syndrome associated with?

Multiple nodules resulting from exposure to certain dusts Signup and view all the answers

Which of the following is NOT a characteristic of Felty's syndrome?

Hypertension Signup and view all the answers

Which hematologic abnormality is rare in rheumatoid arthritis unless associated with certain conditions?

Thrombocytopenia Signup and view all the answers

What does an elevation in sedimentation rate indicate?

Increased clustering of erythrocytes due to inflammation Signup and view all the answers

What is the typical joint pattern of involvement in rheumatoid arthritis?

Usually polyarticular, affecting more than four joints including the wrists and fingers. Signup and view all the answers

What is the sensitivity and specificity of Anti-Cyclic Citrullinated Peptide Antibodies (anti-CCP)?

67% sensitive and 96% specific Signup and view all the answers

Which age group has the peak onset of rheumatoid arthritis?

Individuals in their 5th and 6th decades of life. Signup and view all the answers

What role does IL-6 play in inflammation related to macrophages?

IL-6 stimulates macrophages to produce TNF-alpha and more IL-6. Signup and view all the answers

What is the function of TNF-alpha in the context of osteoclast differentiation?

TNF-alpha promotes the differentiation of Pre-Osteoclasts. Signup and view all the answers

What role do inflammatory cytokines play in osteoporosis among rheumatoid arthritis patients?

Promote osteoclast activation Signup and view all the answers

What symptom is commonly associated with rheumatoid arthritis that typically does not improve with rest?

Joint pain Signup and view all the answers

What is a significant sign associated with severe morning stiffness in rheumatoid arthritis?

Stiffness lasting more than 20 minutes. Signup and view all the answers

Which laboratory feature is associated with acute inflammation?

Increased C-Reactive Protein levels Signup and view all the answers

Which cytokine is known to downregulate inflammation by acting as a receptor antagonist to IL-1?

IL-1 Ra Signup and view all the answers

In the process of immune complex formation, which antibodies are noted to activate complement pathways in the joint?

RF and anti-CCP Abs Signup and view all the answers

Which autoantibody is identified as the most common in rheumatoid arthritis?

Rheumatoid factor (RF) Signup and view all the answers

Which of the following is true regarding the prevalence of rheumatoid arthritis?

The prevalence is higher in Native Americans compared to other populations. Signup and view all the answers

What is the typical white blood cell count in synovial fluid for rheumatoid arthritis?

Greater than 2,000 μL. Signup and view all the answers

What is the role of DKK-1 in the differentiation of osteoblasts?

DKK-1 prevents pre-osteoblasts from maturing into osteoblasts. Signup and view all the answers

Which of the following factors contributes to the higher prevalence rates of rheumatoid arthritis in females?

Hormonal influences. Signup and view all the answers

What accounts for the improved mortality rates associated with rheumatoid arthritis in modern treatment?

Early detection and aggressive treatment strategies. Signup and view all the answers

What is an essential goal of therapy for rheumatoid arthritis?

Achieve remission and no swollen or tender joints Signup and view all the answers

Which of the following drugs is classified as a conventional DMARD?

Methotrexate Signup and view all the answers

Which feature is characteristic of Sjogren’s Disease?

Lymphocytic infiltrate affecting lacrimal and salivary glands Signup and view all the answers

What is a commonly associated autoimmune condition with Sjogren’s Disease?

Rheumatoid Arthritis Signup and view all the answers

The female-to-male ratio of Sjogren’s Disease occurrence is approximately:

9:1 Signup and view all the answers

What triggers the immune response in Sjogren’s Disease?

Viral infection of the salivary glands Signup and view all the answers

Which of the following is a targeted synthetic DMARD?

Baricitinib Signup and view all the answers

In the management of RA, which criteria reflects low disease activity?

Low Global Score and normal ESR Signup and view all the answers

What is the most common initial symptom of Sjogren’s syndrome?

Keratoconjunctivitis Signup and view all the answers

Which antibody is found in approximately 90% of Sjogren’s patients?

Anti-ribonucleoproteins SSA-A (Ro) Signup and view all the answers

What should be done if an enlarged lymph node is discovered in a patient suspected of having Sjogren’s?

Conduct a biopsy Signup and view all the answers

Which of the following is NOT listed as a manifestation of oral complications in Sjogren’s patients?

Dry cough Signup and view all the answers

Which condition is associated with bilateral parotid enlargement?

Cirrhosis Signup and view all the answers

What is a treatment option for managing dry mouth in Sjogren’s syndrome?

Pilocarpine Signup and view all the answers

Which factor does NOT appear to contribute to dry mouth and dry eyes in Sjogren’s syndrome?

Nutritional status Signup and view all the answers

Which symptom is least likely to be reported in patients with Sjogren’s syndrome?

Skin rash Signup and view all the answers

Study Notes

Rheumatoid Arthritis & Sjogren's Disease

Rheumatoid Arthritis (RA) is a chronic systemic and destructive inflammatory arthropathy.
Objectives for the presentation include identifying genetic risk factors, describing signs and symptoms, unique physical findings in late-stage disease, pathogenesis, important cytokines, radiographic characteristics, treatment mechanisms, and possible complications of RA.
The prevalence of RA in the US population is 0.5% to 1%. There are significant differences in prevalence rates within a country, with higher rates in Native Americans like the Pima tribe, and prevalence in some areas of Africa and Asia may be 0.2-0.4%. The female-to-male ratio is 2-3:1.
Incidence is 40/100,000 per year. Peak onset is typically in the 5th and 6th decades of life, often plateauing and then decreasing after age 75.
Prior to aggressive treatment, mortality rates for RA were comparable to Stage 4 Hodgkin's Lymphoma or three-vessel cardiovascular disease, and primarily stemmed from cardiovascular disease, infection, and malignancy. Mortality has improved since then..

RA Signs & Symptoms

Symptoms that do not improve with rest include: pain throughout the day, significant morning stiffness (greater than 20 minutes) after inactivity, fatigue, and generalized weakness. A gradual onset is common.
Signs of RA include: restricted movement, swelling with inflammation, synovial fluid with a white cell count above 2,000/μL, and usually a polyarticular presentation (affecting more than four joints). Fever and weight loss may also be present.

Joint Involvement Pattern in RA

RA usually involves multiple joints (polyarticular), often starting in the wrists, metacarpophalangeal (MCP) joints, the proximal interphalangeal (PIP) joints, and metatarsal joints of the feet.
Later, hips, knees, ankles, elbows, and shoulders can be affected. The upper cervical spine, temporomandibular joint (TMJ), and sternoclavicular (SC) joints may also be impacted.

Hand Involvement in RA vs. OA

RA hand involvement typically affects the MCPs and PIPs more significantly and displays characteristic features like swan neck and boutonniere deformities, and ulnar deviation. This is in contrast to osteoarthritis (OA).
The comparison image illustrated the visual difference in distribution of affected joints between the two diseases.

RA - Other Manifestations

RA can present with a range of non-articular symptoms, including ocular inflammation (uveitis) such as anterior and posterior uveitis. Common ocular manifestations include episcleritis (redness and discomfort), scleritis (inflammation of the sclera , often painful, correlated with vasculitis and long-standing arthritis). Scelromalacia and the presence of painful, often red episcleral nodulosis may also appear.
Other non-articular manifestations include cardiovascular problems like myocarditis (chest pain & exercise intolerance), pericarditis (uncommon, often diagnosed via echocardiogram), coronary artery disease (CAD), heart failure in patients with RA (often preserved ejection fraction, HFpEF), and rare instances of nodules in pericardium, myocardium, and valvular structures potentially causing heart block and sudden death.
Pulmonary involvement can occur, evidenced in up to 73% of RA patients, but fewer exhibit chest symptoms, with pleural effusion seen in 5% and exudative fluid with high protein, low white blood cell count, low glucose, and positive rheumatoid factor (RF). Interstitial lung disease is also a possibility. Nodular, seropositive lung disease is sometimes associated with smoking. Lung nodules, especially in people exposed to coal, asbestos, or silica dust, can occur in some cases.
Hematologic abnormalities include anemia of chronic disease, thrombocytosis (rare, except in drug-treated or Felty's syndrome), thrombocytopenia (rare, related to drug treatment or Felty's), and eosinophilia. Pulmonary complications may be associated with an increase in eosinophils.
Felty's syndrome, a combination of RA, splenomegaly, and leukopenia, is associated with long-standing RA, and bacterial infections are common in its presentation. Immune complexes coat granulocytes, causing sequestration and reduced survival.
Osteoporosis is another potential complication of RA, with inflammation activating osteoclasts, leading to periarticular bone loss.

Laboratory Features

Erythrocyte Sedimentation Rate (ESR): Measures the settling rate of erythrocytes, which accelerates in the presence of inflammatory proteins.
C-Reactive Protein (CRP): An acute phase protein produced by the liver, stable, and increases rapidly during inflammation, normalizing within a week.
Some laboratory markers used to diagnose/monitor RA include Rheumatoid factor (RF), an autoantibody in 75% of affected patients, and Anti-Cyclic Citrullinated Peptide (anti-CCP) antibodies, which are present in about 90% of RA patients. An elevated anti-CCP level has a high specificity for RA.

Classification Criteria of RA

The 2010 American College of Rheumatology/European League Against Rheumatism criteria for classifying RA include joint involvement, serology, acute-phase reactants, and duration of symptoms. Defined parameters with scoring protocols identify the severity of RA and the potential to aid in successful treatment.

Treatment for RA

Conventional Disease-Modifying Antirheumatic Drugs (DMARDs): Include drugs like methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, and azathioprine.
Biological DMARDs (bDMARDs), including anti-TNF therapies like etanercept and adalimumab, chimeric agents like infliximab, anti-IL-1 agents like anakinra, anti-IL-6 agents like tocilizumab or sarilumab, CTLA4-Ig like abatacept, and B-cell depletion agents like rituximab.
Targeted synthetic DMARDs (tsDMARDs) include kinase inhibitors like tofacitinib and baricitinib.
The treatment regimens are often categorized as monotherapy with MTX, or combination therapies (MTX + other bDMARD or tsDMARD). Triple therapy may also be appropriate (MTX, Sulfasalazine, and HCQ).

Sjogren's Disease

Sjogren's disease is a chronic inflammatory disorder affecting the lacrimal and salivary glands. This leads to dryness of the eyes and mouth.
The disease can be primary (occurring alone) or secondary (occurring with other autoimmune diseases, such as RA).

Sjogren's Demographics

Sjogren's disease affects an estimated 1-2 million people in the US.
The female-to-male ratio is 9:1.
The typical age of onset is between 30 and 50.

Sjogren's Pathogenesis

A viral trigger, such as a salivary gland infection, is suspected as an initial impetus for initiating autoimmunity against self-antigens in genetically susceptible persons.
Activated CD4+ T and B cells, which may have escaped tolerance, then react with the specific self-antigens, leading to an inflammatory response and eventual fibrosis of the glands.

Sjogren's Initial Signs & Symptoms

Common initial signs of Sjogren's include: keratoconjunctivitis sicca (dry eyes, 47% of cases), xerostomia (dry mouth, 42%), arthralgia/arthritis (28%), parotid enlargement (24%), Raynaud's phenomenon (21%), and fever/fatigue (10%), and localized dyspareunia (5%).

Sjogren's Oral Manifestations

Sjogren's patients often experience dry mouth, leading to poor dental hygiene including candidiasis (oral fungal infection), and burning in the mouth. Difficulty eating without water is frequently reported.

Sjogren's Differential Diagnosis

Potential causes of dry mouth include various medications (antidepressants, antipsychotics, some diuretics), as well as diabetes or anxiety. Dry mouth is also sometimes linked to HIV, Hepatitis C, or radiation to the neck.
Dry eyes can also have various causes, including Vitamin A deficiency, certain medications (anticholinergics), age, AIDS, or trigeminal nerve or facial paralysis.
Bilateral parotid gland enlargement is observed in conditions like Mumps, diabetes, HIV, Coxsackie virus infections, acromegaly, bulimia, or cirrhosis.

Sjogren's Diagnosis

Diagnosing Sjogren's includes assessing ocular and oral manifestations, alongside evaluating various autoantibodies, including rheumatoid factor (RF), antinuclear antibodies (ANA), and anti-SSA/Ro and anti-SSB/La antibodies. A biopsy of minor salivary glands can confirm lymphocytic infiltration in the glands, which is a characteristic of the disease.

Sjogren's Treatment

Treatment focuses on managing the symptoms of dry eyes and dry mouth, utilizing artificial tears, punctal occlusions (occluding punctal drainage), pilocarpine or cevimeline. Lubricants can also be used for dry mouth. Referral to a dentist for regularly scheduled checkups is also crucial. Hydroxychloroquine may also be utilized to address arthralgia and myalgia, if present.

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Description

Test your knowledge on rheumatoid arthritis with this quiz. It covers genetic alleles, immune responses, and specific syndromes associated with the condition. Challenge yourself and see how well you understand the complexities of RA!