Rheumatoid Arthritis — MCQs
A 30-year-old woman complains of bilateral pain and stiffness in the small joints of her hands, worse in the morning and improving throughout the day. What is the most likely diagnosis?
Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?
A patient of RA is taking methotrexate, steroids and NSAIDs since 4 months but activity of disease progression is same. What should be the next probable step?
A 50-year-old woman with a history of rheumatoid arthritis presents with fever and joint pain. Which laboratory test is most definitive in distinguishing between a rheumatoid flare and an infectious process?
In long standing rheumatoid arthritis, which condition is commonly observed?
All are clinical manifestations of Felty's syndrome except:
A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?
Which of the following is not an extra-articular feature of Rheumatoid arthritis?
A 45-year-old crane operator at a construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. On examination - Rheumatoid nodules are also present. Chest X-ray was performed. What is the diagnosis?
The most specific antibody for Rheumatoid arthritis is?
Rheumatoid Arthritis Indian Medical PG Practice Questions and MCQs
Question 1: A 30-year-old woman complains of bilateral pain and stiffness in the small joints of her hands, worse in the morning and improving throughout the day. What is the most likely diagnosis?
- A. Psoriatic arthritis
- B. Osteoarthritis
- C. Rheumatoid arthritis (Correct Answer)
- D. Gout
Explanation: ***Rheumatoid arthritis*** - This presentation of **bilateral pain and stiffness in the small joints of the hands**, characterized by **morning stiffness that improves with activity**, is highly classic for rheumatoid arthritis [1]. - Rheumatoid arthritis is a **chronic autoimmune inflammatory disease** primarily affecting the synovial joints [2]. *Psoriatic arthritis* - While it can affect hands, it typically presents with **asymmetric joint involvement**, often associated with **skin psoriasis** and **nail changes** [1][3]. - Morning stiffness can occur but less commonly presents with the classic bilateral, symmetrical small joint involvement seen in rheumatoid arthritis. *Osteoarthritis* - Characteristically presents with **pain that worsens with activity** and improves with rest, often described as "wear and tear." - Morning stiffness in osteoarthritis is usually brief (less than 30 minutes), unlike the prolonged stiffness seen in inflammatory arthritis [4]. *Gout* - Gout typically causes **acute, severe, unilateral joint pain**, often in the **first metatarsophalangeal joint** (big toe). - It is caused by the deposition of **uric acid crystals** and does not typically present with bilateral, symmetrical small joint stiffness.
Question 2: Which one of the following is not a diagnostic criterion for rheumatoid arthritis according to the American Rheumatism Association?
- A. Raised rheumatoid factor.
- B. Symmetrical muscle weakness. (Correct Answer)
- C. Symmetric swelling (arthritis) for at least 6 weeks.
- D. Rheumatoid nodules.
Explanation: ***Symmetrical muscle weakness.*** - **Muscle weakness** is not a primary diagnostic criterion for **rheumatoid arthritis (RA)** [1]. While muscle atrophy can occur secondary to chronic inflammation and disuse, it's not a defining feature used in diagnostic classification. Symmetrical proximal muscle weakness is instead a hallmark of conditions like polymyositis [2]. - The diagnostic criteria focus on **inflammatory arthritis**, joint involvement patterns, serological markers, and acute phase reactants [1]. *Raised rheumatoid factor.* - The presence of **rheumatoid factor (RF)**, especially in high titers, is a key serological marker for RA, included in the diagnostic criteria [1]. - While not exclusive to RA, its presence aids in confirming the diagnosis, particularly in conjunction with clinical symptoms. *Symmetric swelling (arthritis) for at least 6 weeks.* - **Symmetric polyarthritis**, particularly affecting the **small joints** of the hands and feet, is a hallmark clinical presentation of RA and a central diagnostic criterion [1], [3]. - The **duration of at least 6 weeks** helps differentiate RA from transient or acute forms of arthritis [1]. *Rheumatoid nodules.* - **Rheumatoid nodules**, subcutaneous swellings typically found over bony prominences, are a characteristic extra-articular manifestation of RA and are included [4]. - Their presence indicates more severe disease and is highly specific for RA [4].
Question 3: A patient of RA is taking methotrexate, steroids and NSAIDs since 4 months but activity of disease progression is same. What should be the next probable step?
- A. Continue methotrexate and steroids
- B. Stop oral methotrexate and start parenteral methotrexate
- C. Add sulfasalazine
- D. Add anti TNF alpha drugs (Correct Answer)
Explanation: ***Add anti TNF alpha drugs*** - This patient has **active rheumatoid arthritis** despite 4 months of treatment with **methotrexate**, **steroids**, and **NSAIDs**, indicating an inadequate response to conventional DMARDs [1]. - Current major rheumatology guidelines (**ACR 2021**, **EULAR 2019**) recommend escalating to **biologic DMARDs** like **anti-TNF-alpha agents** as the preferred next step for patients with persistent disease activity after 3-6 months of methotrexate therapy [1]. *Continue methotrexate and steroids* - Continuing the current regimen unchanged is not appropriate as the patient's **disease activity has not improved** over four months. - This approach would leave the patient at risk for ongoing **joint damage** and functional decline due to **uncontrolled inflammation** [2]. *Stop oral methotrexate and start parenteral methotrexate* - While changing to **parenteral methotrexate** can improve **bioavailability** and absorption, the primary issue here is the **overall lack of disease control**, not necessarily methotrexate non-response [1]. - This step alone is unlikely to provide sufficient additional benefit for a patient whose disease is still active after 4 months, especially when more potent **biologic options** are available [1]. *Add sulfasalazine* - **Sulfasalazine** is a valid conventional synthetic DMARD that can be used in **combination therapy** with methotrexate and has proven efficacy in RA treatment. - However, current major rheumatology guidelines (**ACR 2021**, **EULAR 2019**) recommend escalating to **biologic DMARDs** like **anti-TNF agents** as the preferred next step for patients with inadequate response to methotrexate after 3-6 months, especially when **disease activity remains high** as in this case [1].
Question 4: A 50-year-old woman with a history of rheumatoid arthritis presents with fever and joint pain. Which laboratory test is most definitive in distinguishing between a rheumatoid flare and an infectious process?
- A. Erythrocyte sedimentation rate (ESR)
- B. Joint aspiration and culture (Correct Answer)
- C. C-reactive protein (CRP)
- D. Rheumatoid factor (RF)
Explanation: Detailed joint aspiration and culture is the most definitive step [1]. This procedure directly analyzes synovial fluid for **white blood cells**, **bacteria**, or **crystals**, providing a definitive diagnosis for an infectious process such as **septic arthritis** [1]. *Erythrocyte sedimentation rate (ESR)* - While elevated in both inflammation and infection, the **ESR is a non-specific marker** and cannot differentiate between a rheumatoid flare and an infectious process. - It indicates overall inflammation but does not identify the underlying cause of the inflammation. *C-reactive protein (CRP)* - Similar to ESR, **CRP is an acute-phase reactant** [2]. It increases significantly during both inflammatory conditions and infections [2]. - It is a more sensitive marker for inflammation than ESR but **lacks specificity** to distinguish between inflammatory and infectious etiologies [2]. *Rheumatoid factor (RF)* - **Rheumatoid factor** is an autoantibody primarily associated with **rheumatoid arthritis** and is usually present in patients with the disease. - Its presence or elevated levels would not differentiate between an RA flare and a concurrent infection, as it reflects the underlying autoimmune disease rather than an acute infectious process.
Question 5: In long standing rheumatoid arthritis, which condition is commonly observed?
- A. Milk alkali syndrome
- B. Nephrolithiasis
- C. Paradoxical aciduria
- D. Secondary amyloidosis (Correct Answer)
Explanation: ***Secondary amyloidosis*** - Chronic inflammation in **rheumatoid arthritis** can lead to the production and deposition of **amyloid A protein**, which is the hallmark of secondary (AA) amyloidosis [1]. - **Secondary amyloidosis** can affect various organs, including the kidneys, heart, and gastrointestinal tract, leading to organ dysfunction [1]. *Milk alkali syndrome* - This condition is caused by excessive intake of **calcium** and absorbable alkali, resulting in **hypercalcemia** and **metabolic alkalosis**. - It is not directly associated with the chronic inflammatory process of rheumatoid arthritis. *Nephrolithiasis* - **Kidney stones** (nephrolithiasis) are often associated with genetic predispositions, dietary factors, and certain metabolic conditions like **hypercalciuria** or **hyperoxaluria**. - There is no direct causal link between **rheumatoid arthritis** and an increased risk of common types of kidney stones. *Paradoxical aciduria* - This condition is characterized by the excretion of acidic urine in the presence of **metabolic alkalosis**, typically due to **volume depletion** and **hypokalemia**. - While it reflects a disturbance in acid-base balance and renal function, it is not a direct or commonly observed complication of long-standing rheumatoid arthritis itself.
Question 6: All are clinical manifestations of Felty's syndrome except:
- A. Neutropenia
- B. Nephropathy (Correct Answer)
- C. Rheumatoid arthritis
- D. Splenomegaly
Explanation: ***Nephropathy*** - **Nephropathy** is not a characteristic clinical manifestation of **Felty's syndrome**. While patients with **rheumatoid arthritis** can develop kidney involvement (e.g., secondary amyloidosis) [1], it is not considered part of the core diagnostic criteria or classic presentation of **Felty's syndrome**. - The syndrome specifically involves a triad of features linked to the immune system's overactivity, rather than direct kidney damage. *Neutropenia* - **Neutropenia** (low neutrophil count) is a hallmark feature of **Felty's syndrome**, leading to an increased risk of infections. - It results from the destruction of neutrophils and suppression of bone marrow granulopoiesis. *Rheumatoid arthritis* - **Felty's syndrome** is a severe extra-articular manifestation of **long-standing rheumatoid arthritis**, indicating that the presence of **RA** is a prerequisite [1]. - Patients typically have **seropositive, erosive rheumatoid arthritis** that has been active for many years [1]. *Splenomegaly* - **Splenomegaly** (enlarged spleen) is another key component of **Felty's syndrome**, contributing to the destruction of blood cells [1]. - The enlarged spleen can sequester and destroy neutrophils, further contributing to the neutropenia.
Question 7: A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?
- A. Continue Methotrexate and steroids at higher dose
- B. Stop oral Methotrexate and start parenteral Methotrexate
- C. Add Sulfasalazine (Correct Answer)
- D. Start treatment with anti-TNF alpha drugs
Explanation: Focus on **Add Sulfasalazine**: - Since the patient has not responded to **Methotrexate** alone, adding a second conventional synthetic **disease-modifying antirheumatic drug (DMARD)** like **Sulfasalazine** is a common and appropriate step in a **treat-to-target strategy** for rheumatoid arthritis [1]. - This approach aims to achieve **disease remission** or **low disease activity** by combining therapies to enhance efficacy. *Continue Methotrexate and steroids at higher dose* - Increasing the dose of **Methotrexate** might be considered if the current dose is sub-optimal, but after 4 months with no improvement, simply continuing current medications at higher doses without adding another agent is less likely to significantly alter **disease progression** [1]. - Prolonged higher-dose **steroids** carry significant risks and are generally used for symptom control, not primary disease modification. *Stop oral Methotrexate and start parenteral Methotrexate* - Switching to **parenteral Methotrexate** is considered if **oral Methotrexate** absorption is an issue or if the patient experiences gastrointestinal side effects [1]. - While parenteral administration can improve bioavailability, it doesn't represent a change in therapeutic strategy for **uncontrolled disease activity**. *Start treatment with anti-TNF alpha drugs* - **Biologic DMARDs** like **anti-TNF alpha drugs** are typically reserved for patients who have failed **two or more conventional synthetic DMARDs**, including **Methotrexate**, or in cases of severe, rapidly progressing disease [2]. - While effective, they are more expensive and have different side effect profiles, making them a later-line treatment in the management algorithm [2].
Question 8: Which of the following is not an extra-articular feature of Rheumatoid arthritis?
- A. Conjunctivitis
- B. Pleural effusion
- C. Proteinuria (Correct Answer)
- D. Weight loss
Explanation: ***Proteinuria*** - While kidney involvement can occur in RA (e.g., secondary amyloidosis, drug-induced nephropathy), **proteinuria** itself is not a direct or typical extra-articular feature of rheumatoid arthritis [1]. - It usually indicates a **complication** or secondary condition rather than a primary manifestation of RA. *Conjunctivitis* - **Sjögren's syndrome**, often associated with RA, can cause **dry eyes** (keratoconjunctivitis sicca), which may be described as conjunctivitis-like symptoms [1]. - **Episcleritis** and **scleritis** are also known ocular manifestations of RA, though less common than dry eyes [1]. *Pleural effusion* - **Rheumatoid pleurisy** leading to pleural effusion is a recognized extra-articular manifestation, often characterized by **low glucose levels** in the pleural fluid. - It can be symptomatic (e.g., chest pain, dyspnea) or asymptomatic. *Weight loss* - **Systemic inflammation** and the catabolic state associated with active RA can lead to generalized **fatigue** and **unintentional weight loss** [1]. - This is a common non-specific extra-articular symptom reflecting disease activity.
Question 9: A 45-year-old crane operator at a construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. On examination - Rheumatoid nodules are also present. Chest X-ray was performed. What is the diagnosis?
- A. Caplan syndrome (Correct Answer)
- B. Lung cancer
- C. Bronchiolitis obliterans organizing pneumonia
- D. Felty syndrome
Explanation: Phase ***Caplan syndrome*** - **Caplan syndrome** is characterized by the presence of **rheumatoid arthritis**, lung nodules (usually multiple and bilateral), and a history of exposure to **occupational dusts**, particularly silica or coal dust [2]. The patient's history as a crane operator at a construction site suggests significant occupational dust exposure, fitting this diagnosis. [2] - The combination of pre-existing **seropositive rheumatoid arthritis**, rheumatoid nodules, and progressive difficulty in breathing with chest X-ray findings consistent with lung nodules points strongly to this rare but well-described condition [1], [2]. *Lung cancer* - While lung cancer can present with respiratory symptoms and nodules, the patient's history of **rheumatoid arthritis** and **rheumatoid nodules** makes Caplan syndrome a more specific and likely diagnosis given the occupational exposure. - Without further imaging or biopsy results, attributing the nodules solely to lung cancer would overlook the strong association with his existing autoimmune condition and work environment. *Bronchiolitis obliterans organizing pneumonia* - This condition involves inflammation and fibrosis within the bronchioles and alveoli, leading to respiratory symptoms and patchy infiltrates on chest imaging. - However, it is not typically associated with **rheumatoid nodules** or occupational dust exposure in the same manner as Caplan syndrome, making it less likely in this specific clinical context. *Felty syndrome* - **Felty syndrome** is a triad of **rheumatoid arthritis**, **splenomegaly**, and **neutropenia**. - While the patient has rheumatoid arthritis, there is no mention of splenomegaly or neutropenia, and the predominant respiratory symptoms with lung nodules are not features of Felty syndrome.
Question 10: The most specific antibody for Rheumatoid arthritis is?
- A. Rheumatoid factor
- B. Anti-cyclic citrullinated peptide (anti-CCP) antibody (Correct Answer)
- C. Antinuclear antibody (ANA)
- D. Anti-double stranded DNA antibody
Explanation: ***Anti-cyclic citrullinated peptide (anti-CCP) antibody*** - **Anti-CCP antibodies** specifically target citrullinated proteins, which are implicated in the pathogenesis of rheumatoid arthritis. - Their presence is highly predictive of **rheumatoid arthritis (RA)** and is often used for early diagnosis and prognosis. *Rheumatoid factor* - **Rheumatoid factor (RF)** is an antibody against the Fc portion of IgG, found in about 80% of RA patients [1]. - However, RF can also be present in other conditions like **Sjögren's syndrome**, **chronic infections**, and **healthy individuals**, making it less specific than anti-CCP antibodies. *Antinuclear antibody (ANA)* - **Antinuclear antibodies (ANA)** are a broad group of antibodies targeting components within the cell nucleus. - While often positive in **systemic rheumatic diseases** like lupus, ANA is not specific for rheumatoid arthritis [2]. *Anti-double stranded DNA antibody* - **Anti-double stranded DNA (anti-dsDNA)** antibodies are highly specific for **systemic lupus erythematosus (SLE)** [2]. - They are not typically found in, nor are they diagnostic for, rheumatoid arthritis.
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