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BRS 1b > 9.5 Rheumatoid Arthritis > Flashcards

9.5 Rheumatoid Arthritis Flashcards

1
Q

What are the 2 types of crystal arthritis?

A

gout

pseudogout

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2
Q

What is a tendon?

A

cords of strong fibrous collagen tissue attaching muscle to bone

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3
Q

What is a ligament?

A

flexible fibrous connective tissue which connects two bones

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4
Q

What are the four components of a synovial joint?

A

Bone
Articular cartilage
Synovium
Synovial fluid

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5
Q

Why is chronic inflammation of the synovium bad?

A

leads to permanent damage; inflammatory markers can also attack articular cartilage leaving exposed bone

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6
Q

What is the synovium?

A

1-3 cell deep lining containing macrophage-like-phagocytic cells (type A synoviocyte) and fibroblast-like cells that produce hyaluronic acid (type B synoviocyte)
AND
Type 1 Collagen

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7
Q

What is the synovial fluid?

A

hyaluronic acid-rich viscous fluid

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8
Q

What is the articular cartilage?

A

Type 2 Collagen

Proteoglycan (aggrecan)

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9
Q

What is arthritis?

A

disease of the joints

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10
Q

What are the main two types of arthritis?

A

Degenerative (osteoarthritis)

Inflammatory (rheumatoid)

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11
Q

What is inflammation?

A

A physiological response to deal with injury or infection

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12
Q

What are the 5 clinical manifestations of inflammation?

A 
red (rubor)
pain (dolor)
hot (calor)
swelling (tumor)
loss of function
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13
Q

What are 4 physiological, cellular and molecular changes we see when inflammation occurs? (not 5 clinical manifestations)

A
  • increased blood flow
  • migration of white blood cells (leucocytes) into the tissues
  • activation/differentiation of leucocytes
  • cytokine production (TNF alpha, IL-1,6,17)
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14
Q

What are 3 causes of joint inflammation?

A

Crystal arthritis
Immune mediated-arthritis
Infection

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15
Q

What is crystal arthritis?

A

Inflammation of the joint triggered by crystals of synovial fluid

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16
Q

What is gout?

A

syndrome caused by deposition of monosodium urate (uric acid) crystals

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17
Q

What are the risk factors for gout?

A

high uric acid levels
genetic tendency
increased intake of purine rich foods
reduced excretion (kidney failure)

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18
Q

How does gout present?

A 
abrupt onset (couple of hours)
extremely painful 11/10
joint red, warm, swollen, tender
resolves spontaneously in 3-10 days
affects one large joint - usually big toe
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19
Q

What is pseudogout?

A

syndrome caused by calcium pyrophosphate dihydrate crystal deposition crystals (CPPD)

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20
Q

What are the risk factors for pseudogout?

A

background osteoarthritis
elderly patient
intercurrent infection

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21
Q

What will you see on an X ray showing gout

A

rat bite errosions

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22
Q

How to investigate gout?

A

joint aspiration- synovial fluid analysis

can blood test to show high uric acid levels

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23
Q

What medication is prescribed for gout?

A

acute - colchicine, NSAIDs, steroids

chronic - allopurinol

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24
Q

How are synovial fluid samples examined for pathogens and crystals?

A

rapid gram stain followed by culture and antibiotic sensitivity assays
polarising light microscopy to detect crystals

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25
Q

What will analysis of crystals in gout show?

A

crystal: urate
shape: needle
birefringence (polarising light microscopy): negative

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26
Q

What will analysis of crystals in pseudogout show?

A

crystal: CPPD
shape: brick
birefringence: positive

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27
Q

What is rheumatoid arthritis?

A

chronic autoimmune disease characterised by pain stiffness and symmetrical synovitis

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28
Q

What happens to the synovium in RA?

A
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29
Q

What controls the immune activation in RA?

A

Cytokine network

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30
Q

What causes the synovitis, bone erosion, pannus and cartilage degradation in RA?

A

Excess of pro-inflammatory vs anti inflammatory cytokines

31
Q

What is the main pro-inflammatory cells in RA?

A

TNFa

32
Q

What’s the pattern of joint involvement in RA?

A

Polyarthritis - many joints involved

Affects large and small joints, primarily MCP and PIP in hands

33
Q

What is the primary site of pathology in RA?

A

The synovium

34
Q

What are som extra-articular features of RA?

A

Common:
Fever
Weight loss
Subcutaneous nodules

Uncommon:
Vasculitis
Ocular inflammation
Neuropathies
Amyloidosis
35
Q

What are subcutaneous nodules?

A

Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue

36
Q

What % of RA patients have subcutaneous nodules?

A

30%

Associated with severed disease and extra-articular manifestations and high levels of RF

37
Q

Where is the typical position of the rheumatoid nodule?

A

Ulnar body of forearm

Hands

38
Q

What are the two types of antibodies found in the blood of RA patients?

A
  1. Rheumatoid Factor

2 Antibodies to citrullinated protein antigens (ACPA)

39
Q

What is RF?

A

Antibodies which recognise the Fc portion of IgG antibody

40
Q

How many RA patients are RF positive?

A

70%

Further 10-15% after 2 years of diagnosis

41
Q

What does it mean if a patient is seronegative?

A

Absence of RF (in case of RA)

42
Q

What is the treatment goal of RA?

A

Prevent joint damage

43
Q

What requires successful treatment of RA?

A

Early recognition of symptoms, referral, diagnosis
Joint destruction = inflammation x time
Aggressive treatment

44
Q

What types of drugs are given to RA patients?

A

DMARDs

Disease modifying anti rheumatic drugs = drugs that control the disease process

45
Q

What is the 1st line treatment for RA?

A

Methotrexate with hydroxychlorquine

46
Q

What is the 2nd line treatment for RA?

A

Biological therapies and targeted treatment

47
Q

Why don’t we prescribe prednisolone for RA?

A

Avoid long term use because of side effects

48
Q

What do we use in conjunction with medical treatment for RA?

A

Physiotherapist
Occupational therapy
Surgery
Etc

49
Q

What are biological therapies?

A

Proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

50
Q

What are the 4 biological therapies for RA?

A
  1. Anti TNF (infliximab)
    2 B cell depletion (rituximab)
  2. Modulation of T cell co stimulation
  3. Inhibition of interleukin 6 signalling
51
Q

What is a spondyloarthropathy?

A

Joint disease of vertebrae

52
Q

What does seronegative mean?

A

No positive auto antibodies

53
Q

What is ankylosing spondylitis

A

Seronegative spondyloarthropathy
Chronic sacroillitis - inflammation of sacroiliac joints
Results in spinal fusion

54
Q

What is the common demographic for a patient with AS?

A

20-30 year old male

55
Q

What is AS associated with?

A

HLA B27
Psoriatic arthritis
IBD

56
Q

How does AS present?

A 
Lower back pain
Early morning stiffness - improves with exercise
Reduced spinal movements 
Peripheral arthritis
Plantar fasciitis, Achilles tendinitis
Fatigue 
Hyperextended neck
57
Q

How to we manage AS?

A

Physiotherapy
Exercise regime
NSAIDs
If peripheral joint disease - DMARDs

58
Q

What will we see in the blood for AS?

A

Normocytic anaemia
Raised CRP, ESR
HLA-B27

59
Q

What is HLA-B27?

A

human leukocyte antigen B27

HLA is protein that is found on the surface of white blood cells, tells body it is self

HLA-B27 destroys it, indicated autoimmune disease

60
Q

What would an x ray of AS show?

A 
Squaring vertebral bodies
Erosion, sclerosis 
Narrowing sacroiliac joint
Bamboo spine
Bone marrow oedema
61
Q

What is psoriatic arthritis?

A

Seronegative autoimmune disease affecting the skin (scaly red plaques on extensor surfaces elbows and knees), but patients also have joint inflammation.

Psoriatic arthritis is 10% of psoriasis

62
Q

How can psoriatic arthritis manifest?

A

Classically asymmetrical arthritis affecting IPJs
Can be symmetrical involvement of small joints (rheumatoid pattern)
Spinal and sacroiliac joint inflammation

63
Q

How is psoriatic arthritis investigated?

A

X ray of affected joint - pencil in a cup abnormality (arthritis mutilans)
MRI- sacroilitis (inflammation)
Bloods - nothing as seronegative

64
Q

How is psoriatic arthritis managed?

A

DMARDs - methotrexate

Avoid oral steroids

65
Q

Why are oral steroids avoided in psoriatic arthritis?

A

Risk of pustular psoriasis due to skin lesions

66
Q

What is reactive arthritis?

A

Sterile inflammation of the joints following infection especially urogenital, (Chlamydia) and gastrointestinal (salmonella, campylobacter)

67
Q

What are extra articulate manifestations of reactive arthritis?

A

Enthesitis - tendon inflammation
Skin inflammation
Eye inflammation

68
Q

What can reactive arthritis be the first manifestation of?

A

HIV

Hep c infection

69
Q

What does a typical case of reactive arthritis look like?

A

Young adult with:

  • genetic predisposition (HLA-B27)
  • environmental trigger (salmonella)
70
Q

How long after the initial infection does reactive arthritis occur?

A

1-4 weeks

71
Q

How do we treat reactive arthritis?

A

NSAIDs

DMARDs if required

72
Q

What is lupus?

A

A multi system autoimmune disease

73
Q

What is systemic lupus erthymatous? SLE

A

Multi site inflammation; can affect any organ
Often joints, skin, kidneys.
Associated with autoantibodies directed against components of the cell nucleus

74
Q

What are the clinical tests for SLE?

A

Antinuclear-antibodies (ANA) - high sensitivity for SLE but not specific (negative test rules out)

Anti double stranded DNA antibodies (anti dsDNA Abs) - high specificity in appropriate contex

BRS 1b (25 decks)

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