Which of the following statements about rheumatoid arthritis is true: a) anti‑cyclic citrullinated peptide (anti‑CCP) antibodies are present, b) it involves the spine, c) it is characterized by photosensitivity, d) it affects the distal and proximal interphalangeal joints?

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Regarding Rheumatoid Arthritis: Statement Analysis

Statement (a) is correct: anti-CCP antibodies are present in rheumatoid arthritis, while statements (b), (c), and (d) contain inaccuracies.

Analysis of Each Statement

a) Anti-CCP Antibodies Are Present ✓ CORRECT

Anti-cyclic citrullinated peptide (anti-CCP) antibodies, also known as ACPA (anti-citrullinated protein antibodies), are a hallmark serological marker of rheumatoid arthritis. According to the 2010 ACR/EULAR classification criteria, ACPA positivity contributes 2-3 points toward RA diagnosis depending on titer level (low positive: 2 points; high positive: 3 points) 1.

  • Diagnostic performance: Anti-CCP demonstrates approximately 67-78% sensitivity and 95-96% specificity for RA 2, 3
  • These antibodies are highly specific for RA and can be present early in the disease course, often before clinical symptoms fully manifest 2
  • Anti-CCP positivity is associated with more erosive disease and worse prognosis 4, 5

b) It Affects the Spine ✗ INCORRECT

Rheumatoid arthritis characteristically does NOT involve the spine, except for the cervical spine (particularly C1-C2 atlantoaxial joint). The 2010 ACR/EULAR classification criteria explicitly state that joint assessment for RA excludes the distal interphalangeal joints and focuses on peripheral joints 1.

  • RA primarily affects peripheral joints: metacarpophalangeal (MCP), proximal interphalangeal (PIP), wrists, elbows, shoulders, knees, and ankles 1
  • Spinal involvement (particularly sacroiliitis and thoracolumbar spine) is characteristic of seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis), not RA
  • The differential diagnosis guidelines specifically mention psoriatic arthritis as a condition to distinguish from RA 1

c) It Is Characterized by Photosensitivity ✗ INCORRECT

Photosensitivity is NOT a feature of rheumatoid arthritis. This is a characteristic manifestation of systemic lupus erythematosus (SLE), which is listed as a differential diagnosis to exclude when evaluating for RA 1.

  • The guidelines emphasize excluding SLE when diagnosing RA 1
  • RA presents with joint swelling, morning stiffness, and systemic inflammation—not dermatologic photosensitivity
  • The typical RA rash (when present in conditions like Adult-onset Still's disease) is salmon-pink, evanescent, and maculopapular—not photosensitive 6

d) It Affects the Distal and Proximal Interphalangeal Joints ✗ PARTIALLY INCORRECT

This statement is misleading. RA affects proximal interphalangeal (PIP) joints but characteristically SPARES the distal interphalangeal (DIP) joints.

The 2010 ACR/EULAR criteria explicitly state: "Distal interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints are excluded from assessment" 1.

  • PIP joints ARE involved: These are classified as "small joints" in RA assessment and are commonly affected 1

  • DIP joints are NOT involved: DIP involvement suggests alternative diagnoses such as:

    • Osteoarthritis (Heberden's nodes)
    • Psoriatic arthritis
    • Erosive osteoarthritis

  • The typical RA pattern includes MCP joints, PIP joints (2nd-5th), wrists, and metatarsophalangeal joints (2nd-5th) 1

Clinical Pitfall to Avoid

Do not diagnose RA in patients with isolated DIP joint involvement. This pattern should prompt evaluation for psoriatic arthritis, osteoarthritis, or other conditions. The presence of DIP involvement actually argues AGAINST a diagnosis of RA and should redirect your diagnostic workup 1.

References

1
Guideline

my treatment approach to rheumatoid arthritis.

Mayo Clinic Proceedings, 2012

2
Research

Anti-CCP antibodies: the past, the present and the future.

Nature reviews. Rheumatology, 2011

3
Research

[Anti-cyclic citrullinated peptide antibodies and rheumatoid arthritis].

Rinsho byori. The Japanese journal of clinical pathology, 2010

6
Guideline

diagnosis and management of adult onset still's disease.

Annals of the Rheumatic Diseases, 2006

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