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Meet two patients with chronic joint pain and test your rheumatology knowledge with this quiz! Enjoy!

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Approach to the patient with Chronic Joint Pain

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Question 1

STEM 1, QUESTION 1 OF 5

Janet, a 55-year old female, presents to her GP with symmetrical pain in the small joints of her hands and feet. She has been experiencing this pain for the past 4 months and it is getting worse. The doctor suspects rheumatoid arthritis.
Rheumatoid factor is an autoantibody present in the blood of 60-70% of those with rheumatoid arthritis. Following blood tests, Janet tests negative for rheumatoid factor. Which of the following antibodies is most appropriate to measure following a negative rheumatoid factor test?
A
Anti-centromere (ACA) antibody
B
Anti-cyclic citrullinated peptide (anti-CCP) antibody
C
Anti-double stranded DNA (anti-dsDNA) antibody
D
Anti-neutrophil cytoplasmic (ANCA) antibody
E
Antinuclear (ANA) antibody
Question 1 Explanation: 
Anti-CCP antibodies are often measured following a negative rheumatoid factor test, if rheumatoid arthritis is suspected. These antibodies are found in around 80% of those with rheumatoid arthritis (see https://cks.nice.org.uk/topics/rheumatoid-arthritis/diagnosis/investigations-for-suspected-ra/). Anti-dsDNA antibodies are highly specific markers of SLE. ANCA antibodies are associated with vasculitis. Anti-centromere antibodies are associated with limited cutaneous systemic sclerosis. ANA antibodies can rise in numerous conditions such as systemic lupus erythematosus (SLE) and Sjogren's syndrome.
Question 2

STEM 1, QUESTION 2 OF 5

The patient has some key signs of rheumatoid arthritis in her hands. One of these is Boutonnière deformity. Which of the following correctly describes this deformity?
A
Bending of the fingers towards the ulna bone of the forearm
B
Hyperextended distal interphalangeal (DIP) joint with a flexed proximal interphalangeal (PIP) joint
C
Hyperextended proximal interphalangeal (PIP) joint with a flexed distal interphalangeal (DIP) joint
D
Swelling of the distal interphalangeal joints
E
Swelling of the proximal interphalangeal joints
Question 2 Explanation: 
Boutonnière deformity is a deformity of the finger where the DIP is hyperextended and the PIP is flexed. A way to remember this is that it looks like the finger is pushing a button (Boutonnière = button!). A hyperextended PIP with a flexed DIP is known as swan neck deformity and is also a sign found in rheumatoid arthritis. Bending of the fingers towards the ulna bone of the forearm is a feature of rheumatoid arthritis known as ulnar deviation or ulnar drift. Hard, bony swelling of the DIPs and PIPs are features of osteoarthritis and are known as Heberden's nodes and Bouchard's nodes respectively.
Question 3

STEM 1, QUESTION 3 OF 5

Janet is sent for X-rays of her hands. On X-ray images, which of the following is NOT a hallmark feature of joints affected by rheumatoid arthritis?
A
Erosions
B
Joint space narrowing
C
Osteopenia
D
Osteophytes
E
Soft tissue swelling
Question 3 Explanation: 
Osteophytes are bony spurs that grow around joints. They form next to joints affected by osteoarthritis and are not associated with rheumatoid arthritis.
Question 4

STEM 1, QUESTION 4 OF 5

The patient is prescribed methotrexate. Which of the following should also be prescribed to prevent methotrexate-induced side effects?  
A
Biotin
B
Cholecalciferol (vitamin D)
C
Folic acid
D
Magnesium
E
Riboflavin
Question 4 Explanation: 
Methotrexate is an antifolate antiproliferative. It inhibits dihydrofolate reductase, an enzyme needed for DNA synthesis and immune cell proliferation. Overall, this leads to anti-inflammatory effects. The anti-folate effects of the drug lead to side effects, such as nausea and mouth ulcers. Folic acid is given to prevent these unpleasant side effects. 5mg of folic acid is given once weekly on a different day to the methotrexate dose. See https://bnf.nice.org.uk/drug/methotrexate.html for information on methotrexate and https://bnf.nice.org.uk/drug/folic-acid.html for information on folic acid.
Question 5

STEM 1, QUESTION 5 OF 5

Rheumatoid arthritis is an autoimmune disease. Which of the following genes is associated with the condition?
A
BRCA-1
B
CFTR
C
HLA-DQ8
D
HLA-DR4
E
HFE
Question 5 Explanation: 
HLA stands for Human Leukocyte Antigen. HLAs are protein markers on cells which play an important role in the body's immune system by presenting antigens. Specific types of these proteins are involved in certain autoimmune conditions. HLA-DR4 is associated with rheumatoid arthritis. HLA-DQ8 is associated with coeliac disease. BRCA-1 is a gene associated with an increased risk of breast and ovarian cancers. CFTR gene mutation is associated with cystic fibrosis. The HFE gene encodes a protein involved in iron regulation and HFE mutation is associated with the hereditary iron overload disease, haemochromatosis.
Question 6

STEM 2, QUESTION 1 OF 5

Charlie, a 19-year old male, presents to his GP with lower back pain. He also describes his back as feeling "stiff at times". This has been going on for 3 months
The GP suspects ankylosing spondylitis. Which of the following is NOT characteristic of the pain experienced by patients with this condition?
A
Back pain and stiffness which is worse in the morning
B
Back pain and stiffness which improves with rest
C
Back pain and stiffness which wakes the patient in the night
D
Buttock pain
E
Pain which responds well to NSAIDs
Question 6 Explanation: 
The back pain associated with ankylosing spondylitis is inflammatory in nature. Inflammatory pain is generally worst in the morning and improves throughout the day. Inflammatory pain also improves with movement and worsens with rest. The back stiffness associated with ankylosing spondylitis is also usually worst in the mornings and takes at least 30 minutes to ease. Contrast this to mechanical back pain, which generally improves with rest and is not associated morning stiffness lasting over 30 minutes.
Question 7

STEM 2, QUESTION 2 OF 5

The doctor decides to carry out Schober's test to determine if Charlie's lumbar spine has a decreased range of motion. The skin is marked 10cm above and 5cm below an imaginary horizontal line between Charlie's posterior superior iliac spines (PSIS). Charlie is asked to bend forwards to touch his toes. What is the MINIMUM that the distance between these two points should increase to in patients with normal lumbar flexion?
A
18cm
B
20cm
C
22cm
D
24cm
E
26cm
Question 7 Explanation: 
The distance between the two points should increase by at least 5cm to make the total distance 20cm in patients with normal lumbar flexion. If the distance between the two points is less than 20cm when the patient bends forwards, this indicates limited lumbar flexion - a feature of ankylosing spondylitis.
Question 8

STEM 2, QUESTION 3 OF 5

Which of the following is NOT a complication associated with ankylosing spondylitis?
A
Vertebral fracture
B
Anterior uveitis
C
Restrictive pulmonary disease
D
Liver cirrhosis
E
Cardiovascular disease
Question 8 Explanation: 
There are many complications associated with ankylosing spondylitis. See https://cks.nice.org.uk/topics/ankylosing-spondylitis/background-information/complications/ for more details.
Question 9

STEM 2, QUESTION 4 OF 5

Tumour necrosis factor-alpha (TNF-alpha) inhibitors can be used in the treatment of ankylosing spondylitis (under expert supervision). Which of the following drugs is a TNF-alpha inhibitor?
A
Infliximab
B
Rituximab
C
Sulfasalazine
D
Tacrolimus
E
Trastuzumab
Question 9 Explanation: 
Infliximab is a TNF-alpha inhibitor which can be prescribed by consultant rheumatologists. TNF-alpha inhibitors act to reduce the body's inflammatory response. Trastuzumab and rituximab are monoclonal antibodies used in the treatment of certain types of cancer. Sulfasalazine is an aminosalicylate used in the treatment of Chron's disease, ulcerative colitis, and rheumatoid arthritis. Tacrolimus is used to inhibit the immune system following solid organ transplantation to avoid transplant rejection.
Question 10

STEM 2, QUESTION 5 OF 5

Ankylosing spondylitis is a member of the seronegative spondyloarthropathy family of joint conditions. Which of the following genes is associated with this group of joint conditions and can be tested for as part of the diagnosis of ankylosing spondylitis?
A
HLA-B23
B
HLA-B25
C
HLA-B27
D
HLA-B29
E
HLA-B31
Question 10 Explanation: 
Ankylosing spondylitis is thought to be triggered by environmental factors in those who are genetically susceptible. The most significant genetic risk factor is the HLA-B27 gene. However, it is important to note that not all patients with ankylosing spondylitis are HLA-B27 positive and so it cannot be solely relied on for a diagnosis. See https://cks.nice.org.uk/topics/ankylosing-spondylitis/background-information/causes/ for more information.
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