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BR 3rd Ed > Ch 3 - Rheumatology: RA > Flashcards

Ch 3 - Rheumatology: RA Flashcards

1
Q

What is Rheumatoid arthritis (RA)?

A

Systemic autoimmune inflammatory disorder of unknown etiology
affecting multiple organ systems

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2
Q

What does RA affect in in joints?

A

Synovial lining of diarthrodial joints

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3
Q

What happens to joints in chronic RA?

A

Symmetric erosive synovitis develops in the joints and leads to articular destruction

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4
Q

What is pathognomic of RA?

A

Joint erosions

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5
Q

What is the most important destructive element of RA?

A

Pannus formation

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6
Q

What is a pannus?

A

Membrane of granulation tissue that covers the articular cartilage at joint margins

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7
Q

What do fibroblast-like cells do during pannus formation?

A

Invade and destroy the periarticular bone and cartilage at joint margins

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8
Q

What is vascular granulation tissue composed of?

A

Proliferating fibroblasts
Numerous small BV’s
CD4 T-lymphocytes
Collagen fibers w/in phagolysosomes

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9
Q

What are the genetic factors of RA?

A

– MHC on chr 6

– Class II MHC allele HLA-DR4

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10
Q

What is the epidemiology of RA?

A

Female to male 2:1

20-60 yo peak 40-50

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11
Q

What are the classification categories for RA?

A
  1. Morning joint stiffness
  2. Arthritis of >3 joints
  3. Symmetric arthritis
  4. Rheumatoid nodules
  5. Rheumatoid Factor (RF) +
  6. Radiographic changes
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12
Q

Describe morning stiffness in RA.

A

Must last at least 1 hour before maximal improvement

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13
Q

What are the 14 possible joints involved in RA?

A

Bilateral PIP joints, MCP joints, wrist, elbow, knee, ankle, and MTP joints

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14
Q

What are Rheumatoid nodules?

A

Subcutaneous nodules over extensor surfaces, bony prominences, or in juxta-articular regions

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15
Q

Describe radiographic changes of RA.

A

Erosions, bony decalcification, and symmetric joint-space narrowing seen on hand and wrist X-ray

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16
Q

Describe the MC onset pattern of RA.

A 
Insidious (50-70%) 
Slow onset over weeks to months
Diffuse MSK pain
Morning stiffness
Low grade fever
Joint swelling, erythema
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17
Q

Describe synovial fluid in RA.

A
  • Low viscosity
  • WBC = 1,000–75,000/mm3
  • > 70% PMNs
  • Transparent—cloudy
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18
Q

What % of patients with RA are RF +?

A

85%

Other 15% fulfill other criteria for dx

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19
Q

What are diseases can have RF +?

A 
SLE
Scleroderma
Sjögren’s
Viral
Parasitic
Bacterial
Neoplasms
Hyperglobulinemic
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20
Q

What is the sensitivity and specificity of cyclic citrullinated peptide Abs for RA?

A

80% sensitivity and 90-95% specificity for RA

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21
Q

What other diseases can cyclic citrullinated peptide Abs be seen in?

A

Psoriatic arthritis
TB
Autoimmune hepatitis

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22
Q

What are early radiographic findings in RA?

A

– Soft tissue swelling

– Joint space

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23
Q

What are late radiographic findings in RA?

A

– Uniform joint space narrowing due to loss of articular cartilage (hips, knees, etc.)
– Axial migration of the hip (protrusio acetabuli) – Malalignment and fusion of joints

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24
Q

What is seen near attachment of the joint capsule in RA?

A

Marginal bone erosions

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25
Q

What is bone washout in RA?

A

(+) Juxta-articular osteopenia

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26
Q

What does cervical spine involvement in RA lead to?

A

Cervical atlantoaxial (A-A) subluxation (>2.5 to 3 mm)

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27
Q

What is a Boutonniere deformity?

A

Rupture of central slip of extensor hood of PIP joint causes lateral band subluxation causing PIP flexion, MCP and DIP hyperextension

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28
Q

What causes swan neck deformity in RA?

A
  • Flexor tenosynovitis l/t MCP flexion contracture
  • Contracture of the intrinsic l/t PIP hyperextension
  • Contracture of deep finger flexor muscles and tendons l/t DIP flexion
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29
Q

What causes ulnar deviation of fingers in RA?

A

Weakening of ECU, UCL, RCL l/t wrist radial deviation which inc torque on ulnar finger flexors causing flexor/extensor mismatch and ulnar deviation of fingers when patient tries to extend fingers

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30
Q

Which tendons are involved in de Quervain’s Tenosynovitis?

A

EPB and APL

31
Q

What can early RA be confused with at the wrist?

A

de Quervain’s Tenosynovitis

32
Q

What is the Piano-key sign?

A

Floating ulnar head dorsally in the wrist

33
Q

What causes ulnar head floating?

A

Synovitis at the ulnar styloid l/t rupture or destruction of the UCL l/t laxity of the radioulnar joint

34
Q

What is resorptive arthropathy?

A

Bone resorption l/t shortened digits and phalanges appear retracted w/ skin folds

35
Q

What is the pseudobenediction sign?

A

Stretched radioulnar ligaments allow the ulna to drift upward l/t rupture of 4th and 5th extensor tendons and inability to extend

36
Q

What is the most common direction for Atlantoaxial (A-A) joint subluxation?

A

Anterior

37
Q

What are causes of Atlantoaxial (A-A) joint subluxation in RA?

A
  • Tenosynovitis of the transverse ligament of C1 l/t rupture
  • Odontoid or atlas erosion
  • Basilar invagination
38
Q

What is an abnormal A-A space with cervical flexion?

A

> 2.5 to 3 mm is considered abnormal

39
Q

What is recommended pre-operatively in RA patients?

A

C-spine flexion-extension x-rays are recommended to ensure there is no cervical instability

40
Q

What is Protrusio acetabuli?

A

Inward bulging of the acetabulum into the pelvic cavity

41
Q

What are common ankle deformities in RA?

A
  • Ligament weakness leading to hindfoot pronation

* Tarsal tunnel syndrome

42
Q

What are common foot deformities in RA?

A
  • Hammer toe deformities
  • Claw toe deformities
  • Hallux valgus deformity
43
Q

Which patients are more likely to have extra-articular manifestions of RA?

A

– RF (+)
– Rheumatoid nodules – Severe articular disease
– MHC class HLA DRB1 alleles

44
Q

What are subcutaneous rheumatoid nodules?

A

Form subcutaneously in bursae and along tendon sheaths over pressure points and extensor forearm

45
Q

What can enhance development of subcutaneous rheumatoid nodules?

A

Methotrexate

46
Q

What disorders are subcutaneous nodules seen in?

A

RA

Gout

47
Q

What are vasculitic lesions seen in RA?

A

Leukocytoclastic vasculitis

Palpable purpura

48
Q

What are ocular manifestions of RA?

A
  • Keratoconjunctivitis sicca (dry eye syndrome) • Episcleritis
  • Scleritis
49
Q

What are pulmonary manifestions of RA?

A
  • Interstitial lung disease
  • Pulmonary fibrosis
  • Pleurisy
  • Inflammation of the cricoarytenoid joint
  • Bronchiolitis obliterans
50
Q

What is Caplan’s syndrome?

A
  • Intrapulmonary nodules histologically similar to rheumatoid nodules
  • RF (+)
  • Assoc w/ RA and pneumoconiosis in coal workers
  • Granulomatous response to silica dust
51
Q

What are the classic findings of pericarditis?

A

Chest pain
Pericardial friction rub
EKG: diffuse ST elevations

52
Q

What is Xerostomia?

A

Dryness of the mouth secondary to decreased salivary secretion

53
Q

What type of anemia is seen in RA?

A

Hypochromic-microcytic anemia

54
Q

What is Felty’s Syndrome?

A

Classic triad of RA, splenomegaly, leukopenia

55
Q

Which patient’s get Felty’s sydnrome?

A
  • Seropositive RA w/ nodules
  • 5th or 7th decades w/ RA > 10 years
  • 2/3 Women
  • Assoc w/ leg ulcers
56
Q

What type of rehab is done in acute RA?

A

Severely inflamed joints, actual splinting is used to produce immobilization with twice-daily full and slow passive range of motion to prevent soft-tissue contracture

57
Q

What type of exercise should be used with mild RA?

A

Mild disease (moderate synovitis) requires isometric program

58
Q

What are the benefits of isometric exercise?

A

– Least periarticular bone destruction and joint inflammation/pain
– Restores and maintains strength
– Max muscle tension with min work, fatigue, and stress

59
Q

What types of exercise should be avoided in RA?

A

Isotonic and isokinetic exercise may exacerbate the flare and should be avoided

60
Q

Why should superficial most heat not be used in acutely inflamed joints?

A

Increases collagenase enzyme activity that causes increased joint destruction

61
Q

What are indications for orthotics in RA?

A
  • Dec pain and inflammation
  • Red wt through joint
  • Joint stabilization
  • Joint rest
62
Q

What is the therapeutic range for ASA?

A

ASA is 15 to 25 mg/dL

Toxic > 30 mg/dL

63
Q

What are types of Nonbiological disease-modifying antirheumatic drug (DMARD)?

A 
Hydroxychloroquine
Sulfasalazine
Methotrexate
Leflunomide
Cyclosporine
Gold intramuscular, oral
Azathioprine
64
Q

What are side effects of Hydroxychloroquine?

A

Retinopathy

Hyperpigmentation

65
Q

What are side effects of Sulfasalazine?

A

Myelosuppression

GI disturbances

66
Q

What are side effects of Methotrexate?

A 
Stomatitis
Myelosuppression
Hepatic fibrosis
Cirrhosis
Pulmonary involvement
Worsens rheumatoid nodules
Teratogenicity
67
Q

What are side effects of Leflunomide?

A

Hepatotoxicity
N/D
HTN
Teratogenicity

68
Q

What are side effects of Cyclosporine?

A 
Renal dysfunction
Tremor
Hirsutism
HTN
Gum dysplasia
69
Q

What are side effects of Gold intramuscular, oral?

A

Myelosuppression
Proteinuria
Diarrhea (#1, oral)
Rash (#1, intramuscular)

70
Q

What are side effects of Azathioprine?

A

Myelosuppression
Hepatotoxicity
Lymphoproliferative disorders

71
Q

Where is a synovectomy MC in RA?

A

Extensor tenosynovitis at wrist

72
Q

Where are athrodesis MC in RA?

A

Ankle

73
Q

What are poor prognostic factors of RA?

A
  1. Rheumatoid nodules 2. RF (+)
  2. X-ray consistent with erosive disease
  3. Persistent synovitis
  4. Insidious onset
  5. CCP antibodies

BR 3rd Ed (92 decks)

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