Arthritides: Inflammatory and Degenerative — MCQs

10 questions

Earliest radiographic finding in rheumatoid arthritis

Which of the following represents important radiological differentiating features between psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis?

A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?

Deformity is most commonly seen in primary osteoarthritis of the knee joint -

In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?

Which of the following statements about osteoarthritis is false?

Arthritis mutilans is seen in?

Earliest investigation for diagnosis of Ankylosing spondylitis:

The PRIMARY mechanisms that cause increased bone density (sclerosis) on X-ray include: a) Increased thickening of trabeculae b) Fracture & Collapse of cancellous bone c) Defective mineralization d) Myositis ossificans

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Which imaging modality is best for evaluating retinoblastoma?

Arthritides: Inflammatory and Degenerative Indian Medical PG Practice Questions and MCQs

Question 1: Earliest radiographic finding in rheumatoid arthritis

A. Subluxation
B. Erosions
C. Periarticular osteopenia (Correct Answer)
D. Joint space narrowing

Explanation: ***Periarticular osteopenia*** - This is often the **earliest radiographic finding** in **rheumatoid arthritis**, reflecting bone demineralization around the inflamed joint. - It results from the inflammatory processes and increased vascularity in the synovium, leading to enhanced **osteoclast activity**. *Subluxation* - This is a **late consequence** of extensive joint destruction and ligamentous laxity in rheumatoid arthritis. - It indicates significant structural damage, which typically occurs **after** earlier signs like osteopenia and erosions. *Erosions* - While characteristic of rheumatoid arthritis, **bone erosions** are usually seen after periarticular osteopenia has developed. - They represent focal areas of bone destruction due to the inflamed synovium invading and damaging the adjacent bone. *Joint space narrowing* - This finding occurs due to the gradual **destruction of articular cartilage** and is commonly seen in later stages. - While a defining feature of chronic arthritis, it often appears **after** periarticular osteopenia and sometimes coincident with initial erosions.

Question 2: Which of the following represents important radiological differentiating features between psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis?

A. Radiological patterns and joint distribution (Correct Answer)
B. Laboratory markers and genetic associations
C. Clinical presentation and extra-articular features
D. Spinal involvement patterns

Explanation: ***Radiological patterns and joint distribution*** - **Radiological patterns and joint distribution** are the most important radiological differentiating features among these three arthropathies. - **Psoriatic arthritis**: Asymmetric distribution, DIP joint involvement, pencil-in-cup deformity, periostitis, and sausage digit appearance; can involve spine with asymmetric sacroiliitis and bulky syndesmophytes. - **Rheumatoid arthritis**: Symmetric polyarticular involvement of MCP, PIP, and wrist joints (DIP spared), periarticular osteoporosis, marginal erosions, uniform joint space narrowing, and subluxations. - **Ankylosing spondylitis**: Predominantly axial involvement with bilateral symmetric sacroiliitis, bamboo spine appearance, thin marginal syndesmophytes, squaring of vertebral bodies, and enthesitis. - These distinct **radiological patterns** allow differentiation based on imaging alone. *Laboratory markers and genetic associations* - While **laboratory markers** (rheumatoid factor, anti-CCP, HLA-B27) and **genetic associations** are important for diagnosis, they are **not radiological features**. - The question specifically asks for **radiological** differentiating features, making this option incorrect despite its clinical importance. - Laboratory data complements imaging but cannot be visualized on radiographs, CT, or MRI. *Clinical presentation and extra-articular features* - **Clinical presentation** and **extra-articular features** (skin psoriasis, uveitis, inflammatory bowel disease) are crucial for diagnosis but are **not radiological features**. - These are clinical findings obtained through history and physical examination, not through imaging studies. - Though they guide which imaging to order, they don't represent radiological differentiating features themselves. *Spinal involvement patterns* - While **spinal involvement patterns** are radiologically visible and help differentiate ankylosing spondylitis from rheumatoid arthritis, this option is too narrow. - It doesn't account for peripheral joint patterns which are crucial for differentiating psoriatic arthritis and rheumatoid arthritis (both can have minimal spinal involvement). - **Radiological patterns and joint distribution** is more comprehensive, encompassing both axial and peripheral manifestations across all three conditions.

Question 3: A middle aged female presents with polyarthritis with elevated rheumatoid factor and ANA levels, which among the following will help you to differentiate rheumatoid arthritis from SLE?

A. Soft tissue swelling at the proximal interphalangeal joint
B. Articular erosions on X-ray (Correct Answer)
C. Elevated ESR
D. Juxta articular osteoporosis on X-ray

Explanation: ***Articular erosions on X-ray*** - Articular erosions are classic radiographic hallmarks of **rheumatoid arthritis (RA)**, indicating destructive changes to cartilage and bone [1]. - While both RA and **Systemic Lupus Erythematosus (SLE)** can cause polyarthritis, erosive disease is characteristic of RA and generally absent in SLE [1]. *Soft tissue swelling at the proximal interphalangeal joint* - **Soft tissue swelling** can occur in both RA and SLE due to inflammation, making it a non-specific finding for differentiation [2]. - Both conditions frequently affect the **proximal interphalangeal (PIP) joints**, causing swelling and tenderness [2]. *Elevated ESR* - An **elevated Erythrocyte Sedimentation Rate (ESR)** is a general marker of inflammation and can be high in both RA and SLE [3]. - It reflects ongoing disease activity but does not help to distinguish between these two specific autoimmune conditions. *Juxta articular osteoporosis on X-ray* - **Juxta-articular osteoporosis** can be seen in both RA due to regional bone loss from inflammation and in SLE, often as a side effect of corticosteroid use. - This finding is therefore not specific enough to definitively differentiate between RA and SLE.

Question 4: Deformity is most commonly seen in primary osteoarthritis of the knee joint -

A. Genu varus (Correct Answer)
B. Genu valgum
C. Genu recurvatum
D. Flexion contracture

Explanation: ***Genu varus*** - **Genu varus** (bow-legged deformity) is the most common angular deformity seen in **primary osteoarthritis of the knee**, particularly due to greater wear in the medial compartment. - This deformity places increased stress on the medial compartment, exacerbating the progression of osteoarthritis in that region. *Genu valgum* - **Genu valgum** (knock-knee deformity) is less common in primary knee osteoarthritis compared to genu varus. - It typically results from greater involvement of the **lateral compartment** of the knee joint. *Genu recurvatum* - **Genu recurvatum** is characterized by hyperextension of the knee joint. - This deformity is often associated with ligamentous laxity or neuromuscular conditions, rather than being the primary or most common deformity in knee osteoarthritis. *Flexion contracture* - A **flexion contracture** refers to the inability to fully extend the knee, causing the knee to be perpetually bent. - While common in advanced knee osteoarthritis due to pain, muscle spasm, and joint space narrowing, it is a contracture, not an angular deformity like genu varus or valgus.

Question 5: In a patient presenting with a painful swollen joint and a history of high uric acid levels, which condition is most likely indicated by this clinical presentation?

A. Gout (Correct Answer)
B. Ankylosing spondylitis
C. Osteoarthritis
D. Rheumatoid arthritis

Explanation: ***Gout*** - **Gout** is characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints, most often the **big toe** [1],[2]. - A history of **high uric acid levels** (hyperuricemia) is a primary risk factor, as it leads to the formation of **uric acid crystals** in the joint [1],[3]. *Ankylosing spondylitis* - This condition is a chronic inflammatory disease primarily affecting the **spine and sacroiliac joints**, causing stiffness and pain, especially in the morning. - It is not directly associated with **high uric acid levels** or generally presenting as an acute, single swollen joint attack. *Osteoarthritis* - **Osteoarthritis** is a degenerative joint disease characterized by the breakdown of cartilage over time, leading to pain and stiffness, especially with activity. - While it can cause joint swelling, it is typically a gradual process, not an acute, intensely painful attack, and is not linked to **uric acid levels**. *Rheumatoid arthritis* - **Rheumatoid arthritis** is an autoimmune disease causing chronic inflammation, primarily affecting multiple small joints symmetrically. - It presents with prolonged morning stiffness and is not directly caused by **high uric acid levels**, nor is its typical presentation an acute monoarthritis.

Question 6: Which of the following statements about osteoarthritis is false?

A. Progressive softening of the articular cartilage
B. It is an inflammatory arthritis (Correct Answer)
C. Does not involve synovial joints
D. Does not produce marginal osteophytes

Explanation: ***It is an inflammatory arthritis*** - This statement is **false** because **osteoarthritis (OA)** is fundamentally a **degenerative joint disease**, not a primary inflammatory arthritis. - While it can have an inflammatory component, this is secondary to cartilage breakdown, and it does not share the systemic inflammatory features of conditions like rheumatoid arthritis. *Does not involve synovial joints* - This statement is false because **osteoarthritis** primarily affects **synovial joints**, such as the knees, hips, and hands. - It involves the progressive degeneration of articular cartilage within these synovial joints, leading to pain and dysfunction. *Progressive softening of the articular cartilage* - This statement is true, as **progressive softening of the articular cartilage** is a key pathological feature of **osteoarthritis**. - This softening precedes fibrillation and eventual loss of cartilage, leading to bone-on-bone contact and further joint damage. *Does not produce marginal osteophytes* - This statement is false because the formation of **marginal osteophytes** (bone spurs) is a hallmark feature of advanced **osteoarthritis**. - These bony outgrowths develop at the joint margins as the body attempts to repair or stabilize the damaged joint.

Question 7: Arthritis mutilans is seen in?

A. Rheumatoid arthritis
B. Spondyloarthropathy
C. Reactive arthritis
D. Psoriatic arthropathy (Correct Answer)

Explanation: ***Psoriatic arthropathy*** - **Arthritis mutilans** is a severe, destructive form of psoriatic arthritis characterized by marked **osteolysis** and telescoping deformities of the digits [1]. - This condition is almost exclusively associated with **psoriatic arthritis**, representing its most aggressive subtype [1]. *Rheumatoid arthritis* - While rheumatoid arthritis can cause severe joint destruction, it typically manifests as **erosive arthritis** with joint deformities like **swan-neck** and **boutonnière deformities**, but not true arthritis mutilans [3]. - The pattern of bone destruction (osteolysis) seen in arthritis mutilans is distinct from the erosions in rheumatoid arthritis. *Spondyloarthropathy* - This is a broad category that includes diseases like ankylosing spondylitis and reactive arthritis, which primarily affect the **axial skeleton** and entheses. - While some spondyloarthropathies can cause peripheral joint involvement, they generally do not lead to the extreme osteolysis and telescoping digits characteristic of arthritis mutilans. *Reactive arthritis* - Reactive arthritis is an aseptic inflammatory arthritis that often follows infection, characterized by **oligoarthritis**, dactylitis, and enthesitis [2]. - This condition does not typically cause the severe, mutilating joint destruction seen in arthritis mutilans.

Question 8: Earliest investigation for diagnosis of Ankylosing spondylitis:

A. CT scan
B. Bone scan
C. X-ray
D. MRI STIR sequence (Correct Answer)

Explanation: ***MRI STIR sequence*** - An **MRI STIR (Short Tau Inversion Recovery) sequence** is highly sensitive for detecting early inflammatory changes in the **sacroiliac joints** and spine, such as **bone marrow edema**, which is a hallmark of early ankylosing spondylitis. - It can identify disease activity and structural changes *before* they are visible on conventional X-rays, making it the earliest diagnostic tool. *CT scan* - While a **CT scan** provides excellent detailed images of bone, it is not as sensitive as MRI for detecting early inflammatory changes like **bone marrow edema** in the sacroiliac joints. - It involves significant **radiation exposure** and is typically used for more advanced structural assessment rather than early diagnosis. *Bone scan* - A **bone scan** (scintigraphy) shows areas of increased bone turnover but is **not specific** for ankylosing spondylitis and has lower spatial resolution compared to MRI. - It can indicate inflammation or increased metabolic activity but cannot differentiate specific causes or provide detailed anatomical information as effectively as MRI. *X-ray* - **X-rays** are often the initial imaging modality due to their accessibility, but they only show **structural changes** (like erosions, sclerosis, or fusion) in the sacroiliac joints and spine at a later stage of the disease. - Early inflammatory changes, such as **bone marrow edema**, are typically not visible on plain radiographs, leading to a delay in diagnosis compared to MRI.

Question 9: The PRIMARY mechanisms that cause increased bone density (sclerosis) on X-ray include: a) Increased thickening of trabeculae b) Fracture & Collapse of cancellous bone c) Defective mineralization d) Myositis ossificans

A. ac
B. ab (Correct Answer)
C. bc
D. ad

Explanation: ***ab*** - Increased **thickening of trabeculae** directly leads to more bone substance per unit volume, which appears as increased density or sclerosis on X-rays due to greater attenuation of radiation. - **Fracture and collapse of cancellous bone** results in impaction and compaction of bone tissue, increasing its density and thus appearing sclerotic on imaging. *ac* - While **increased thickening of trabeculae** contributes to sclerosis, **defective mineralization** (option c) actually leads to **osteomalacia** or **rickets**, characterized by **decreased bone density**, not increased density. *ad* - **Increased thickening of trabeculae** causes sclerosis. However, **myositis ossificans** (option d) involves the formation of ectopic bone within muscle tissue—a specific condition causing localized calcification/ossification outside the normal bone structure, not a primary mechanism for generalized bone density increase or sclerosis of existing bone. *bc* - **Fracture and collapse of cancellous bone** can contribute to sclerosis. However, **defective mineralization** (option c) would lead to **reduced bone density**, making this combination incorrect for explaining increased bone density.

Question 10: Which imaging modality is best for evaluating retinoblastoma?

A. Ultrasonography
B. CT scan
C. CT scan and MRI (Correct Answer)
D. MRI

Explanation: **Explanation:** Retinoblastoma is the most common primary intraocular malignancy in children. The diagnosis and staging require a multi-modal imaging approach, making **CT scan and MRI** the combined gold standard. * **Why CT and MRI are both essential:** * **CT Scan:** It is the most sensitive modality for detecting **intraocular calcification**, which is the hallmark of retinoblastoma (seen in >90% of cases). CT is crucial for confirming the diagnosis when clinical findings are ambiguous. * **MRI:** It is the modality of choice for **staging**. MRI provides superior soft-tissue contrast to evaluate for optic nerve invasion, extraocular extension, and intracranial involvement (such as trilateral retinoblastoma involving the pineal gland). Crucially, MRI avoids ionizing radiation, which is vital in these patients who often have a genetic predisposition to secondary malignancies (RB1 mutation). **Analysis of Incorrect Options:** * **A. Ultrasonography:** While useful for initial screening and detecting calcified masses (showing high reflectivity with acoustic shadowing), it is operator-dependent and cannot assess posterior extension or intracranial spread. * **B & D. CT or MRI alone:** While both are powerful, neither is sufficient on its own for a complete evaluation. CT excels at identifying pathognomonic calcification, while MRI is mandatory for assessing the extent of the disease and planning management. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Leukocoria (white pupillary reflex) in a child under 3 years. * **Trilateral Retinoblastoma:** Bilateral retinoblastoma associated with a pineal gland tumor (Pineoblastoma). * **Imaging Sign:** "Cloud-like" or "clumpy" calcification on CT. * **Management Tip:** Avoid biopsy (fine-needle aspiration) due to the high risk of tumor seeding along the needle track. Diagnosis is based on clinical exam and imaging.

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