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Y4 Lecture Day II > Inflammatory arthritis > Flashcards

Inflammatory arthritis Flashcards

1
Q

Spectrum of Inflammatory arthritis

(4) categories and examples of disease

A
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2
Q

What to ask in Hx for the joint pain possibly being rheumatoid?

A

*Sicca symptoms: dry mouth, dry eyes

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3
Q

What to look for during clinical examination in the suspected rheumatoid joint?

A
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4
Q

Typical history of rheumatoid arthritis

A
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5
Q

Examination findings of early RA

A
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6
Q

(3) features of rheumatoid hand deformity

A
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7
Q

Characteristic deformities in RA

A

Joint and tendon destruction may lead to deformities such as:

  • ulnar deviation
  • boutonnieres
  • swan neck deformity
  • hammer toes of feet
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8
Q

What’s that the sign of?

A

In RA

Tenosynovitis → inflammation of the tendon and its enveloping tendon sheath

  • associated tendon rupture due to tendon and ligament involvement
  • most commonly involving the fourth and fifth digital extensor tendons at the wrist

* may also cause Carpal Tunnel syndrome

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9
Q

What other joints (other than hands and wrists) may be involved in RA?

A
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10
Q

What are rheumatoid nodules and what are they composed of?

A
  • marker of disease severity → poor outcome
  • commonly found at sites of trauma

Composed of:

  • monocytes
  • macrophages & few lymphocytes
  • fibrinoid material
  • collagen
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11
Q

Manifestations of heart involvement in RA

A
  • pericarditis
  • rheumatoid nodules
  • endocarditis and heart valve
  • vasculitis
  • accelerated Ischaemic heart disease
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12
Q

Manifestations of lung involvement in RA

A
  • Pleural effusion
  • Rheumatoid nodules
  • Fibrosis/interstitial lung disease
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13
Q

Bone, nervous system and other involvement in RA

A
  • Bone – osteoporosis
  • Nervous system – neuropathy, cervical myelopathy (if atlanto-axial joints affected)
  • Other – lymphadenopathy and splenomegaly
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14
Q

Ocular manifestations of RA

A
  • keratoconjunctivitis sicca (most common)
  • episcleritis (erythema)
  • scleritis (erythema and pain)
  • corneal ulceration
  • keratitis

Iatrogenic

  • steroid-induced cataracts
  • chloroquine retinopathy
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15
Q

Skin manifestation of RA (2)

A
  • ulceration
  • vasculitis
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16
Q

Ix (other than imaging) for RA

A
  • ESR & CRP
  • FBC
  • U&E
  • LFT
  • Urinalysis
  • Rheumatoid factor
  • Anti-CCP antibodies
  • Urate if suspecting crystal arthropathy
  • Synovial fluid: yellow colouration, many polymorphonuclear leucocytes
17
Q

Characteristics of synovial fluid in RA

A

Synovial fluid:

  • yellow colouration
  • many polymorphonuclear leucocytes
18
Q

Imaging modalities (4) in the investigation of RA

A
  • X-ray
  • USS
  • MRI
  • DEXA to assess bone density
19
Q

Characteristic X-ray findings in RA

A

Early x-ray findings

  • loss of joint space
  • juxta-articular osteoporosis
  • soft-tissue swelling

Late x-ray findings

  • periarticular erosions
  • subluxation
  • *L** loss of joint space (narrowing)
  • *E** erosions
  • *S** soft tissue swelling
  • *S** soft bones (osteopenia)
20
Q

Management of RA

  • overal
  • initial
  • flares
A

Overall: DMARDs, analgesia, physiotherapy and surgery

Initial therapy

  • DMARD monotherapy +/- a short-course of bridging prednisolone

Flares

  • corticosteroids - oral or intramuscular
21
Q

How do we monitor response to RA therapy?

A

CRP + DAS28

22
Q

When shall we start DMARDs in a patient with RA?

A

Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible

23
Q

Examples of DMARDs therapy for RA (commonly used)

A
  • methotrexate is the most widely used DMARD
  • sulfasalazine
  • leflunomide
  • hydroxychloroquine
24
Q

Monitoring and SEs of Methotrexate

A

Monitoring: FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis

Other important side-effects include pneumonitis

25
Q

TNF inhibitors in therapy of RA

  • when to introduce
  • examples (names)
A

TNF-inhibitors

  • the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate

Examples: etanercept, infliximab, adalimumab

26
Q

Etanercept

  • MoA
  • SEs
A

Etanercept

TNF inhibitor

MoA: recombinant human protein, acts as a decoy receptor for TNF-α

SEs:

  • SC administration → can cause demyelination
  • reactivation of tuberculosis
27
Q

Infliximab

  • MoA
  • SEs
A

Infliximab

  • TNF inhibitor

MoA: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors

  • IV administration

SEs: reactivation of tuberculosis

28
Q

Adalimumab

  • MoA
  • administration
A

Adalimumab

TNF - inhibitor

MoA: monoclonal antibody

Administration: SC

29
Q

SEs of sulfasalazine

A

Sulfasalazine

  • Rashes
  • Oligospermia
  • Heinz body anaemia
  • Interstitial lung disease
30
Q

SEs of Leflunomide

A

Leflunomide

  • Liver impairment
  • Interstitial lung disease
  • Hypertension
31
Q

SEs of Hydroxychloroquine

A
  • Retinopathy
  • Corneal deposits
32
Q

SEs of Prednisolone

A
  • Cushingoid features
  • Osteoporosis
  • Impaired glucose tolerance
  • Hypertension
  • Cataracts
33
Q

SEs of Penicillamine

A
  • Proteinuria
  • Exacerbation of myasthenia gravis
34
Q

SEs of NSAIDs

A
  • Bronchospasm in asthmatics
  • Dyspepsia
  • peptic ulceration
35
Q

Poor prognostic features in RA

A

Poor prognostic features

  • rheumatoid factor positive
  • poor functional status at presentation
  • HLA DR4
  • X-ray: early erosions (e.g. after < 2 years)
  • extra articular features e.g. nodules
  • insidious onset
  • anti-CCP antibodies
36
Q

Triad of Felty’s syndrome

A

Felty’s syndrome

  • RA
  • splenomegaly
  • low white cell count

Y4 Lecture Day II (12 decks)

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