Inflammatory arthritis Flashcards
Spectrum of Inflammatory arthritis
(4) categories and examples of disease
What to ask in Hx for the joint pain possibly being rheumatoid?
*Sicca symptoms: dry mouth, dry eyes
What to look for during clinical examination in the suspected rheumatoid joint?
Typical history of rheumatoid arthritis
Examination findings of early RA
(3) features of rheumatoid hand deformity
Characteristic deformities in RA
Joint and tendon destruction may lead to deformities such as:
- ulnar deviation
- boutonnieres
- swan neck deformity
- hammer toes of feet
What’s that the sign of?
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
What other joints (other than hands and wrists) may be involved in RA?
What are rheumatoid nodules and what are they composed of?
- marker of disease severity → poor outcome
- commonly found at sites of trauma
Composed of:
- monocytes
- macrophages & few lymphocytes
- fibrinoid material
- collagen
Manifestations of heart involvement in RA
- pericarditis
- rheumatoid nodules
- endocarditis and heart valve
- vasculitis
- accelerated Ischaemic heart disease
Manifestations of lung involvement in RA
- Pleural effusion
- Rheumatoid nodules
- Fibrosis/interstitial lung disease
Bone, nervous system and other involvement in RA
- Bone – osteoporosis
- Nervous system – neuropathy, cervical myelopathy (if atlanto-axial joints affected)
- Other – lymphadenopathy and splenomegaly
Ocular manifestations of RA
- keratoconjunctivitis sicca (most common)
- episcleritis (erythema)
- scleritis (erythema and pain)
- corneal ulceration
- keratitis
Iatrogenic
- steroid-induced cataracts
- chloroquine retinopathy
Skin manifestation of RA (2)
- ulceration
- vasculitis
Ix (other than imaging) for RA
- ESR & CRP
- FBC
- U&E
- LFT
- Urinalysis
- Rheumatoid factor
- Anti-CCP antibodies
- Urate if suspecting crystal arthropathy
- Synovial fluid: yellow colouration, many polymorphonuclear leucocytes
Characteristics of synovial fluid in RA
Synovial fluid:
- yellow colouration
- many polymorphonuclear leucocytes
Imaging modalities (4) in the investigation of RA
- X-ray
- USS
- MRI
- DEXA to assess bone density
Characteristic X-ray findings in RA
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)
Management of RA
- overal
- initial
- flares
Overall: DMARDs, analgesia, physiotherapy and surgery
Initial therapy
- DMARD monotherapy +/- a short-course of bridging prednisolone
Flares
- corticosteroids - oral or intramuscular
How do we monitor response to RA therapy?
CRP + DAS28
When shall we start DMARDs in a patient with RA?
Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible
Examples of DMARDs therapy for RA (commonly used)
- methotrexate is the most widely used DMARD
- sulfasalazine
- leflunomide
- hydroxychloroquine
Monitoring and SEs of Methotrexate
Monitoring: FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis
Other important side-effects include pneumonitis
TNF inhibitors in therapy of RA
- when to introduce
- examples (names)
TNF-inhibitors
- the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
Examples: etanercept, infliximab, adalimumab
Etanercept
- MoA
- SEs
Etanercept
TNF inhibitor
MoA: recombinant human protein, acts as a decoy receptor for TNF-α
SEs:
- SC administration → can cause demyelination
- reactivation of tuberculosis
Infliximab
- MoA
- SEs
Infliximab
- TNF inhibitor
MoA: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors
- IV administration
SEs: reactivation of tuberculosis
Adalimumab
- MoA
- administration
Adalimumab
TNF - inhibitor
MoA: monoclonal antibody
Administration: SC
SEs of sulfasalazine
Sulfasalazine
- Rashes
- Oligospermia
- Heinz body anaemia
- Interstitial lung disease
SEs of Leflunomide
Leflunomide
- Liver impairment
- Interstitial lung disease
- Hypertension
SEs of Hydroxychloroquine
- Retinopathy
- Corneal deposits
SEs of Prednisolone
- Cushingoid features
- Osteoporosis
- Impaired glucose tolerance
- Hypertension
- Cataracts
SEs of Penicillamine
- Proteinuria
- Exacerbation of myasthenia gravis
SEs of NSAIDs
- Bronchospasm in asthmatics
- Dyspepsia
- peptic ulceration
Poor prognostic features in RA
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
Triad of Felty’s syndrome
Felty’s syndrome
- RA
- splenomegaly
- low white cell count
