4th Exam: clinical Path Conference

Question 1

Case:

Answer 1

46yo woman, morning stiffness, fingers and wrist, progressive over last 6mo, swelling-fingers, wrist, prominent in MP joints (stiff), 10lb weight loss, red knuckles, Lab: CBC [RBCs, WBCs, platelets] normal, ANA [anti-nuclear Ab] titer 1:320 (< 1:40), Sed rate (ESR) 56 (< 20), Rheumatoid factor elevated to 90 (< 20), Anti-CCP [cyclic citrullinated peptide] Ab > 60 (< 10)

Question 2

Types of arthritis:

Answer 2

Osteoarthritis, RA, Crystal-induced, infectious, enthesitis

Question 3

RA:

Answer 3

Serum IgM anti-IgG (rheumatoid factor), serum cyclic citrullinated peptide Abs – very specific, MP and PIP joints, rheumatoid nodules, systemic disease

Question 4

Citrullinated proteins may:

Answer 4

provoke IR

Question 5

How are MP and PIP joints affected in RA?

Answer 5

Pain, erythema, swelling

Question 6

RA begins as:

Answer 6

synovitis

Question 7

synovitis:

Answer 7

Synovium growth over joint space (pannus), destroys articular cartilage & joint, weakening of ligaments-subluxation: partial dislocation, Fibroblast-like synovial cells proliferate, produce cytokines, matrix metalloproteinases which digest cartilage, inflammation + reactive granulation tissue, forms the pannus which grows over the cartilage

Question 8

RA is assoc with:

Answer 8

Sicca Syndrome (Sjorgen’s, right)?)

Question 9

RA Pathogenesis:

Answer 9

Assoc w viral infection (EBV), HLA-DR genes, smoking, loss of tolerance, molecular mimicry, abnormal citrullination of peptides

Question 10

TF? Some RA pts are seroneg.

Answer 10

T. heterogenous group of diseases

Question 11

HLA-DR Genes:

Answer 11

DR1, DR4, DR10, DR14, strongest assoc is DRB1 alleles

Question 12

DRB1 alleles:

Answer 12

Share hypervariable 5 aa segment in Beta-chain (shared epitope), Ag-binding focus / rheumatoid pocket, presumed binding site of arthritogenic Ag’s

Question 13

Infections with the strongest ties to RA:

Answer 13

EBV

Question 14

How can infections lead to RA?

Answer 14

Activation of self-reactive lympho (loss of tolerance), infectious Ag may cross-react w host Ag (molecular mimicry)

Question 15

How is smoking related to RA?

Answer 15

Abnormal citrullination of peptides, smokers make Abs to citrullinated peptides

Question 16

Early cell type of RA:

Answer 16

PMN’s

Question 17

Later cell type of RA:

Answer 17

Plasma cells and B cells

Question 18

Helper cell related to RA and function:

Answer 18

TH17, makes IL-17, recruits polys

Question 19

Early RA X-ray:

Answer 19

Periarticular (surrounding a joint) osteopenia (reduced bone mass)

Question 20

Late RA X-ray:

Answer 20

loss of articular cartilage

Question 21

inflammatory cells related to RA:

Answer 21

PMNs, plasma cells, B cells, TH17 cels, T cells, Macs, Synovial cells

Question 22

Hand involvement in RA:

Answer 22

Joints involved (PIP, MCP). Joints: swollen, red, deformed, subluxating (off center)

Question 23

RA Nodules of RA:

Answer 23

Extra-articular nodules, granuloma-like, occur in many organs, looks like a tophus (chalky deposit of sodium urate occurring in gout, most often around joints in cartilage, bone, bursae, and subcutaneous tissue), need history to distinguish

Question 24

Sicca Syndrome:

Answer 24

Typical ex: Sjogren’s syndrome, AI, dry eyes, mouth, inflammation of lacrimal and salivary glands