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Review Question - QID 216732

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QID 216732 (Type "216732" in App Search)
A 41-year-old woman presents to her primary care physician with a 6-month history of increasing joint pain. She says that she has been feeling pain in her hands and knees that is worse when she wakes up and gets better over the course of the day. She is only able to walk about 3 blocks before she has to stop because of the pain. She has tried taking acetaminophen but does not feel like it helps much. On physical exam, she is found to have swelling of her metacarpophalangeal joints bilaterally. Activation of which of the following cell types is primarily responsible for the pathophysiology of this disease?

Chondrocytes

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Macrophages

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Osteoclasts

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Tenocytes

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Th1 and Th17

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This patient who presents with progressive joint pain that is worse in the morning, as well as deformity of the metacarpophalangeal (MCP) joints, most likely has rheumatoid arthritis. This disease is caused by the activation of Th1 and Th17 cells.

The pathogenesis of rheumatoid arthritis is not completely understood, but both environmental and genetic factors appear to play a role. This disease is thought to start after a triggering event such as an infection in a genetically susceptible patient. The inflammatory milieu of this event results in the activation of Th1 cells and Th17 cells. Th1 cells release interferon-γ (IFN-γ) in order to activate macrophages and synovial cells. Th17 cells secrete interleukin-17 (IL-17) in order to recruit monocytes and neutrophils. Together, these immune cells result in pannus formation and damage to the adjacent cartilage and bone.

Burska et al. study the inflammatory cells that are involved in the pathogenesis of rheumatoid arthritis. They find that Th17 cell activity may be used as a diagnostic biomarker for this disease.

Incorrect Answers:
Answer 1: Chondrocyte activation appears to be involved in the pathogenesis of osteoarthritis because the proteoglycan composition of cartilage changes early in the course of this disease. Osteoarthritis would present with pain that is worse with use and usually does not involve the MCP joints.

Answer 2: Macrophages are primarily activated in crystalline arthropathies such as gout because the crystals cause a foreign body reaction to occur. Gout usually affects the first metatarsophalangeal joint rather than the hands.

Answer 3: Osteoclasts are primarily activated in Paget disease of bone and result in disorganized bone remodeling. These patients may also present with musculoskeletal pain, but this is usually located over the bone and not the joints.

Answer 4: Tenocytes are primarily activated in diseases that affect sites of enthesis such as ankylosing spondylitis. This disease presents primarily in young men and would affect the sacroiliac joint.

Bullet Summary:
Th1 and Th17 cells are activated in rheumatoid arthritis and result in inflammatory pannus formation with subsequent joint erosion.

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