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MAPP > Inflammatory Arthritis > Flashcards

Inflammatory Arthritis Flashcards

1
Q

Define Rheumatoid Arthritis (RA)

A

A systemic, chronic inflammatory autoimmune disorder involving symmetrical inflammatory arthritis of synovial joints and various extra-articular manifestations.

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2
Q

What is the aetiology of RA?

A

It is thought that the causation of RA involves…
- The interaction of:
Genetic predisposition (HLA DRB1 gene) and environmental risk factors (Smoking, periodontitis, female gender, obesity, aging)

  • Combined with exposure to an unknown pathogen/ disturbance of the immune system that initiates the autoimmune reaction within synovial membranes (key cytokines involved are TNF-a and interleukin-1)
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3
Q

Describe the pathological process of RA within synovial joints

A

Swelling of synovial membrane, effusion of synovial fluid into joint space and hypertrophy of inflamed synovial membrane

Joint effusion, soft-tissue swelling, ligamentous instability occurs.

Invasion of inflamed synovial membrane – inflammatory granulation tissue (pannus) spreads over articular cartilage

Erosion of articular cartilage, loss of joint space, subchondral bone invasion, deformity and ankylosis

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4
Q

What is the common joint pattern of involvement in RA?

A

RA is a symmetrical polyarthritis - affects 5 or more joints at the same time, and appears symmetrically on both sides of the body

Tends to start in the hands and feet

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5
Q

Who does RA usually affect?

A

Can occur at any age but typically diagnosed between 30-50

Male: Female = 1:2-3

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6
Q

What are some common symptoms of early RA?

A

Joint Stiffness - early morning stiffness lasting >30mins

Persistent Joint Swelling - in one or more joints

Positive Squeeze Test - pain when squeezing the MCP or MTP joints

Basically signs of active synovitis in multiple joints

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7
Q

What are some common MSK pathological features present in long standing RA?

A

Upper Limb…
Poor grip strength in hands
Subluxation of MCP joints and ulnar drift
“Swan neck” and “Boutonnière” deformities at IPJs of fingers
Carpal tunnel syndrome
Fixed flexion deformities of the elbows

Lower Limb…
Knee involvement is common - fixed flexion deformity of knee
Valgus knee deformity - due to collateral and cruciate laxity and erosion on tibial plateau
Popliteal cysts - fluid filled swelling posterior to knee
Pesplanovalgus deformity of ankle
HAV
Lesser toe deformities

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8
Q

What extra-articular features are common in RA?

A

Vascular Complications…
Raynauds
Vasculitis - can cause accelerated atherosclerosis and increased risk of CVD and PVD

Muscular Disorders…
Cachexia - muscle weakness and atrophy secondary to joint deformity

Rheumatoid nodules - vascular granulation tissue with central area of necrosis, occurring at sites of pressure or bony prominences

Neurological Complications…
Higher incidence of entrapment/compression neuropathies
Peripheral neuropathy - due to chronic vasculitis

Cardiorespiratory Complications…
Inflammation of the lining lungs leading to pleural effusions and pulmonary fibrosis
Inflammation of the tissue surrounding the heart leading to pericarditis

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9
Q

Describe the common podiatric implications of RA

A

Deformities - Pesplanovalgus, HAV, claw/hammer/retracted toes

Tendon sheath inflammation - Tibialis Posterior Tendon Dysfunction (TPTD) and peroneal tenosynovitis

Tendon and fascia inflammation - Plantar Fasciitis and Achilles tendinitis

Bursitis - Retro-calcaneal or inter-metatarsal bursitis

Synovitis of small joints - MTPJs, IPJs, midfoot and tarsal joints, talocrual joint e.t.c

Widening of the forefoot due to inflammation of internal structures and joint capsules - Daylight’s sign

Irritation/ compression of interdigital nerves due to inflammation of forefoot structures - PDN

Soft tissue pressure lesions - Plantar metatarsal callosities, dorsal HD due to lesser toe deformities

Raynaud’s disease

Peripheral neuropathy

Increased risk of ulceration due to:
Joint deformities
Soft tissue pressure lesions
Increased risk of macro and microvascular diesease, PVD etc
Increased risk of peripheral sensory neuropathy and loss of protective sensation

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10
Q

What tests are used to measure the disease activity of RA?

A

DAS 28 and DAS 44 (Disease Activity Score)
Measures of global disease activity used by rheumatologists to measure global disease activity and inform treatment decisions

DAS 28 is a composite score…
Number of swollen joints
Number of tender joints
Levels of inflammation in the blood (ESR or CRP)
Global health VAS (100mm)

Score of >5.1 = active disease
Score of <3.2 = low disease activity
Score of <2.6 = remission

Does not include foot or ankle joints

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11
Q

How is RA pharmacologically managed?

A

Analgesics e.g Codeine - for pain relief

Topical medicaments e.g Capsicum cream - for pain relief

NSAIDs e.g Naproxen, Ibuprofen, Celecoxib - to reduce inflammation and manage pain

Oral or IA/ IM Corticosteroids e.g Prednisolone - to suppress inflammation

Conventional Synthetic DMARDs e.g Methotrexate, Sulfasalazine - to suppress immune system and inflammatory response

Biologic DMARDs e.g
Anti TNF - Adalimumab, Infliximab, Etanercept
B-cell depletion - Rituximab
T-cell depletion - Abatacept
IL-6 signalling - Tocilizumab
To powerfully suppress the immune system by targeting and inhibiting specific inflammatory cytokines

Targeted Synthetic DMARDs e.g Janus Kinase (JAK) inhibitors such as Tofacitinib, Baricitinib, Filgotinib - to suppress the immune system by
Inhibiting the production of Janus Kinase enzymes (which are required for phosphorylation of activated cytokines receptors)

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12
Q

Define the term “spondaloarthropathy”

A

Spondaloarthropathies (SpAs) are a group of inflammatory arthritic conditions that share certain clinical and histological features…
A common genetic background (HLA-B27 positive)
The absence of RH factor (Seronegative)

‘Spondylo’ = spine or vertebrae, meaning these conditions often affect the back, pelvis and neck

Similar to RA, these conditions involve pain, swelling, stiffness and deformity

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13
Q

What conditions fall under the definition of an SpA?

A

Psoriatic Arthritis

Enteropathic Arthritis

Ankylosing Spondylitis

Reactive Arthritis

Remember the mnemonic P.E.A.R

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14
Q

What clinical features differentiate SpAs from other inflammatory arthropathies like RA?

A

Spinal/Axial involvement

Joint involvement pattern is usually asymmetrical oligo-articular (4 joints affected), poly-articular (5 joints or more) or mono-articular

Peripheral involvement usually begins in the distal IPJs

Enthesitis, sarcoiliitis, dactylitis, uveitis and urethritis are common in patients with SpAs

Presence of HLA-B27 gene is common in about 30-90% of patients with SpAs

Certain shared co-morbidities such as aortic regurgitation, pulmonary fibrosis and amyloidosis are common

The onset age is usually under 45 years

Males are often more symptomatic than females

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15
Q

What is psoriatic arthritis (PsA)?

A

A chronic, progressive, autoimmune, inflammatory arthritis linked with the skin condition psoriasis.

Age of onset = 30-50 years

HLA-B27 positive

Anodular peripheral (typically asymmetrical) arthritis - can present as oligoarthritis, polyarthritis (symmetrical), arthritis multicans, distal IPJ predominant, spondylitis with or without sarcoiliitis

Has extra-articular manifestations such as…
Dactylitis
Enthesitis
Tenosynovitis
Psoriatic skin lesions and nails
Forefoot deformities

Associated with synovitis and juxta-articular erosions with new bone formation (proliferation AND destruction of bone) - can involve increased bone density in shaft of bone

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16
Q

What is the CASPAR criteria?

A

A criteria for the diagnosis of PsA:
Patient must have inflammatory articular disease (peripheral, axial or enthesitis) plus greater than or equal to 3 points from the following…

Psoriasis - current = 2 points, history of or family history = 1 point

Nail Dystrophy (Onycholysis, Pitting, Hyperkeratosis of nail or subungal tissues) - 1 point

Negative RH Factor - 1 point

Dactylitis - current or history of = 1 point

Juxta-Articular New Bone Formation on X-Ray of Hand/Foot - 1 point

17
Q

What would an X-Ray of either the hand or foot of a person with long-standing PsA most likely show?

A

Juxta-articular bone erosions in addition to new bone formation

This can affect the phalanges of the digits resulting in a pointed toe pulp/ ‘telescoping’ of the digits - sometimes described as having a ‘licked candycane’ appearance

This can contribute to what is known as a ‘pencil in cup’ deformity, where a resorted bone articulating with a bone with new bone growth resembles a pencil in a cup

PsA can involve what is called an ivory shaft, which means increased bone density in the shaft of the bone

18
Q

What is dactylitis the sum of?

A

Diffuse swelling of a single digit due to…

Synovitis,
Tenosynovitis,
& Enthesitis…

…Of a digit’s tendon and ligament insertions

19
Q

Describe the pathogenesis of enthesitis

A

Micro-trauma (due to mechanical overloading in gait), leads to micro-damage of the entheses, which can lead to fissuring of the structure and vascular invasion of systemic inflammation.

This leads to inflammation of the entheses, with inflammatory invasion into surrounding bone (osteitis), which can cause erosion (osteolysis) and proliferation (hyperostosis)

This can lead to bone spurs which have a ‘fluffy’ appearance on X-ray

In the foot this commonly effects the…

Achilles tendon insertion
Insertion of the plantar fascia on the calcaneus
Insertion of the plantar fascia the metatarsal heads
Base of the fifth metatarsal head
Tibial tuberosity,
Superior and inferior poles of the patella
Iliac crest

20
Q

How is PsA treated?

A

Similar to RA:
NSAIDs, DMARDS, Biologics, IA corticosteroids, management of soft tissue pathologies and ulceration

However nail care is often more common in PsA due to nail dystrophy and spinal involvement making it difficult to manage nail length and hard skin e.t.c

21
Q

What is ankylosing spondylitis (AS)?

A

An inflammatory autoimmune condition involving inflammation of the apophyseal joints of the spine, the sacroiliac joints and entheses. If untreated, it can cause fusion of the spine and sacroiliac joints.

Age of onset = 20-30 years, occurs predominantly in young men (M:F = 2.5-5:1)

HLA-B27 positive

Key symptoms:
Lower back pain + stiffness
Hip pain + stiffness
Joint pain and swelling in shoulders, knees and ankles
Limited range of motion at spine and hips
Chronic stooping (thoracic kyphosis) to relieve symptoms

Extra-articular manifestations include…
Enthesitis
Eye Inflammation
Fatigue + Fever
Weight Loss + Low Appetite
Peripheral Neuropathy (Cauda equina syndrome is a rare complication of AS)

22
Q

How does joint fusion occur in AS?

A

Fusion occurs due to growth of syndesmophytes, which are bony growths originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae.

Syndesmophytesare pathologically similar to osteophytes, which are bony growths that can occur in osteoarthritis. Fusion of the spine in ankylosing spondylitis is typically referred to as a ‘Bamboo spine’ due to its resemblance to bamboo

23
Q

What is the modified New York criteria?

A

A criteria for diagnosis of AS…
Probable AS if 3 of the following clinical criteria are present or radiologic criteria present without signs and symptoms:

Clinical criteria:
Lower back pain for longer than 3 months, improves upon activity but not relived by rest

Restriction of motion of the lumbar spine in both the saggital and frontal planes

Restriction of chest expansion relative to normal values

Radiological criteria:
Sarcoiliitis grade 2 or higher bilaterally or grade 3-4 unilaterally

24
Q

How is AS treated and managed?

A

Physiotherapy - to minimise postural deformity and maintain mobility of the spine and other joints

Analgesics

DMARDS - if peripheral arthritis is present

Podiatric Management - of enthesitis manifestations (Achilles tendonitis and plantar fasciopathy)

25
Q

What is reactive arthritis?

A

An aseptic acute arthritis that occurs subsequent to an extra-articular infection, typically following 1-3 weeks (max of 6) after a gastrointestinal or genitourinary infection (sub-category of ReA is sexually acquired most commonly by chlamydia).

Usually self limited and resolved within a matter of a few weeks or within 3 months (up to 6 months)

Linked to HLA-B27 gene, people with it have a greater chance of developing ReA following infection

Most common in men between 20-40 years of age and

Presents as a mono or asymmetrical inflammatory oligoarthritis mainly affecting the lower limb - knees, ankle, MTPJs (can also affect hands, elbow and sacroiliac joints). Causes painful swelling within joints (synovitis)

26
Q

What does the saying “Can’t see, can’t pee, can’t climb a tree” mean in relation to ReA?

A

It refers to the three main clinical features of ReA…
Conjunctivitis

Urethritis

Arthritis

27
Q

What is enteropathic arthritis?

A

Inflammatory arthritis which may accompany inflammatory bowel diseases such as ulcerative colitis or Crohn’s disease. Bowel and joint symptoms occur independently

Pattern of joint involvement is similar to other SpAs

This type of arthritis is variable course and includes 2 main types

28
Q

Describe the two types of enteropathic arthritis

A

Type 1
Affects approx 5% of patients with IBD

Typically peripheral arthritis, usually self limiting, common in knees

Enthesitis of AT and PF and dactylitis may occur.

Usually self limiting, joint symptoms may precede bowel symptoms

Type 2
Affects approx 3% of patients with IBD

Usually polyarticular principally affecting MCPs, knees, ankles, elbows, shoulders, wrists, PIPs, MTPs

20% of patients with either form of IBD may present with sacroiliitis or spondylitis

29
Q

What are the extra-articular manifestations of ReA?

A

Extra-articular manifestations include…
Malaise + Fatigue
Uveitis + Conjunctivitis
GI Disturbances e.g diarrhoea
Urethritis
Rashes affecting the genitals (or potential cervicitis in women)
Keratoderma Blennorrhagica (scaley rashes that occur on hands or feet)
Can cause enthesitis and dactylitis
Macules, vesicles or pustules on palms

MAPP (9 decks)

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