Inflammatory Seropositive Arthritis: RA, SLE, Sjogrens, Scleroderma

Question 1

Rheumatoid arthritis
-pathophysiology
-risk factors
-presentation
-investigations
-monitoring response
-management

Answer 1

Synovial inflammation => joint damage

Genetic (HLA DR4) + environmental (smoking)

Female 30-40
Symmetrical - PIP, MCP, MTP
Morning stiffness (30mins+)
Swelling
Fatigue
Constitutional - fever, weight loss
Insiduous onset, gradual development
Extra-articular manifestations
-rheumatoid nodules

RF - more sensitive but associated with other conditions
Anti CCP - more specific

Xray changes - LESS
-loss of joint space
-erosions (late)
-soft tissue swelling
-soft bones (early osteopenia/osteoporosis)

Monitor CRP, DAS28

Initial DMARD therapy - methotrexate
-must monitor FBC (myelosuppression), LFT (cirrhosis)
Inadequate response to 2 DMARDs => TNF inh
-infliximab, adalimumab
-must do CXR before hand to assess risk of TB reactivation

Flares - IA/IM CS

Question 2

Extraarticular presentation of RA

Answer 2

Resp - IDL, effusion, nodules, methotrexate pneumonitis

Eyes - dry eyes, episcleritis, scleritis, keratitis

Inflammation => osteoporosis, CVD

Medication - IC

Impact of condition - depression

Question 3

SLE
-pathophysiology
-risk factors
-presentation
-investigations
-monitoring response
-management

Answer 3

T3 hypersensitivity - HLA B8, DR2-3
-immune complex formation => deposits in tissues

Genetic
Environmental
-UV light
-drug induced - procainamide, hydralazine, isonaizid

Systemic - fever, weight loss
Joint - non erosive arthritis, Raynaud’s, nailfold capillaries
Skin - photosensitivity, malar/discoid rash, non scarring alopecia, livedo reticularis
Mouth - ulcers
Renal - lupus nephritis
Resp - pleuritis
CV - pericarditis
Neuropsych - headache, seizure, psychosis

FBC
High ESR with normal CRP
ANA - most important test
Anti dsDNA - specific
U&E - deranged in lupus nephritis (proteinuria, haematuria)

4/11 signs => diagnosis

Initial - HCQ + NSAID
Mild flare - add PO/IM GC
Moderate - add IV
Severe - cyclophosphamide, rituximab considered

Regular urinalysis for lupus nephritis

Question 4

Lupus nephritis
-presentation, investigations
-management

Answer 4

Proteinuria
Reduced GFR
HTN
Edema

Management
-HTN + CS + azathiopurine

Question 5

Sjogrens syndrome
-pathophysiology
-relationship with other AI conditions
-presentation
-investigations
-management

Answer 5

AI affecting exocrine glands => mucosal dryness
-primary or secondary to RA, other connective tissue disorders

Female
Dry eyes, mouth, vagina
Muscle, joint pain, Raynauds

Clinical diagnosis
Schirmer’s test - assess tear production with filter paper
AntiRo, La, ANA, RF - not specific

Artificial saliva, tears
Pilocarpine

Question 6

Systemic sclerosis
-pathophysiology
-risk factors
-types

Answer 6

Chronic AI connective tissue - fibrosis of skin, internal organs, vasculature, immune dysregulation

Female, 60-70s

Limited - eg CREST
-calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasia
Diffuse

ANA in all
CREST - anti centromere
Diffuse - anti scl70

Early - low dose steroid
Late - symptomatic

Question 7

Drug induced lupus
-presentation
-causative drugs
-how to differentiate from SLE
-management

Answer 7

Arthralgia
Myalgia
Skin + lung involvement
-malar rash
-pleurisy

PROCAINAMIDE
ISONIAZID
HYDRALAZINE

ANA +ve
dsDNA -ve
ANTI HISTONE +ve
anti-Ro, Smith +ve

Stop causative meds