APLAR Grand Round Blackboard – 2026 – Asia Pacific League of Associations for Rheumatology (APLAR)

Question 1

A 48-year-old woman comes to the physician because of a 11-month history of joint pain and stiffness in her wrists and fingers. The symptoms are worse in the morning and improve with activity after 2 hours. Physical examination shows swelling and warmth over the MCP and wrist joints in both hands. An Х-ray of the hands is shown. Synovial biopsy from an affected joint would most likely show which of the following?
Question 1*
- A. Noninflammatory superficial fibrin deposits
- B. Monosodium urate crystals
- C. Noncaseating granulomas
- D. Proliferation of granulation tissue
Answer with a detailed explanation
D. Proliferation of granulation tissue
This patient has evidence of advanced rheumatoid arthritis, based on the findings of marginal erosions on imaging. Microscopic evaluation of a synovial biopsy would most likely show granulation tissue with mononuclear cells, also referred to as pannus. Synovial fluid analysis in this patient would be expected to show neutrophilic infiltrate, increased proteins, reduced viscosity, and possibly rheumatoid factor.
Reference
Cajas LJ, Casallas A, Medina YF, Quintana G, Rondón F. Pannus and rheumatoid arthritis: Historic and pathophysiological evolution. Rev Colomb Reumatol. 2019;26:118–128
Bresnihan B. Are synovial biopsies of diagnostic value?. Arthritis Res Ther. 2003; 5(6): p.271. doi: 10.1186/ar1003
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Question 2

A 37-year-old woman comes to the physician because of progressive pain and stiffness in her hands and wrists for the past 1 year. Her hands are stiff in the morning; the stiffness improves as she starts her chores. Physical examination shows bilateral swelling and tenderness of the wrists and metacarpophalangeal joints. Her range of motion is limited by pain. Laboratory studies show an increased erythrocyte sedimentation rate. This patient's condition is most likely associated with which of the following findings?
Question 2*
- A. IgG antibodies with a TNF-α binding domain on the Fc region
- B. HLA-DQ2 proteins on white blood cells
- C. HLA-B27 protein on white blood cells
- D. IgM antibodies against the Fc region of IgG
Answer with a detailed explanation
D. IgM antibodies against the Fc region of IgG
Rheumatoid factors (RF) are a group of IgM autoantibodies that target the Fc region of IgG. Although elevated RF is classically associated with RA, the sensitivity of RF for RA is estimated to be around 41%–66% for early RA and 62%–87% for established RA, while the specificity accounts for 43%–96%. The level of RF in serum typically increases over the course of RA. Note: Increased RF levels may be physiological or caused by other autoimmune and infectious diseases.
A more specific serological parameter for RA is anti-citrullinated peptide antibodies (ACPA).

Reference
Nicolò A, Amendt T, El Ayoubi O, Young M, Finzel S, Senel M, Voll RE and Jumaa H (2022) Rheumatoid factor IgM autoantibodies control IgG homeostasis. Front. Immunol. 13:1016263.doi: 10.3389/fimmu.2022.1016263
Alexander T, Sarfert R, Klotsche J, et al. The proteasome inhibitior bortezomib depletes plasma cells and ameliorates clinical manifestations of refractory systemic lupus erythematosus. Ann Rheum Dis 2015;74: 1474–1478.
Motta F, et al. RMD Open 2023;9:e002817. doi:10.1136/rmdopen-2022-002817
Pertsinidou E, Saevarsdottir S, Manivel VA, et al. In early rheumatoid arthritis, anticitrullinated peptide antibodies associate with low number of affected joints and rheumatoid factor associates with systemic inflammation. Ann Rheum Dis 2024;83:277–287.
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APLAR Grand Round Blackboard – 2026

Step 1 of 3

Question 1

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Question 2

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Question 3

Which HLA-DRB1 alleles are classically linked with increased RA risk?

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