Intro To Rheum P2 Flashcards
What are the two ways you can classify joint?
Either by structure or function
What are the three different types of joints using structural classification?
Fibrous joints
Cartilaginous joints
Synovial joints
What are fibrous joints?
No space between the bones for example sutures in the skull
What are cartilaginous joints and an example?
Joints in which the bones are connected by cartilage such as in the spine
What are synovial joints and an example?
Joints Which have a space between the adjoining bones and the space is filled with synovial Fluid
E.g knees
What 3 categories can joints be classified into based of function?
Synarthroses (no movement)
Amphiarthroses (limited movement)
Diarthroses(free movement)
What does Synarthroses mean?
No movement joints
What does Amphiarthroses mean?
Limited movement of joints
What does Diarthroses mean?
Free movement of the joint
What is this?
Synovium membrane
What is this?
Articular cartilage
What is this?
Joint cavity containing synovial fluid
What does the Synovium contain
Type one collagen
Type A &B synoviocytes
What does articular cartilage contain?
Type 2 collagen
Aggrecan
What is cartilage composed of?
Chondrocytes and extracellular matrix
What is the most relevant proteoglycan present in Cartilage?
Aggrecan
What are the three main categories of autoimmune arthritis?
Rheumatoid arthritis
Seronegative arthritis
lupus and related disorders
What extra articular diseases can occur in rheumatoid arthritis?
Subcutaneous nodules
Lung disease
Ocular inflammation
Vasculitis
Neuropathies
Felty’s syndrome
What does this image show and what condition shows this feature?
Episcleritis seen in rheumatoid arthritis
What is feltys syndrome?
A rare condition characterised by the triad of splenomegaly, leukopenia and RA
What is splenomegaly?
Enlarged spleen
What does this image show?
Rheumatoid/subcutaneous nodules
What do subcutaneous/rheumatoid nodules contain?
Central area of fibrinoid necrosis (dead tissue) surrounded by histiocytes (macrophages)
Describe the pathogenesis of rheumatoid arthritis?
- in RA, elevated TNF- alpha levels
- causes neovascularisation lymphangiogenesis + production of inflammatory cells
- Synovium = inflamed
- It proliferates it form a mass of tissue = pannus 
What factors cause the synovium to proliferate and form a pannus?
Neovascularisation (in growth of new blood vessels)
Lymph angiogenesis
Inflammatory cells
What is the dominant cytokine in rheumatoid arthritis?
TNFa (tumour necrosis factor -alpha)
What does TNF-a do in RA?
Bone erosion
Pain,joint swelling
Joint space narrowing
What would the blood test findings be in a px with RA (Hb, MCV, WCC, PLT, ESR, CRP)?
What 2 auto antibodies are seen in RA?
Rheumatoid factor
Antibodies to citrullinated proteins antigens (ACPA)
How do we detect rheumatoid factor?
Use IgM antibodies against that recognise the Fc portion of IgG (autoantibody)
Essentially use an antibody against an antibody
Why is the presence of rheumatoid factor only indicative of rheumatoid arthritis not diagnostic?
Has a very low specificity
If px has negative result def doesn’t have RA
BUT if has positive, may not necessarily have it
What is citrullination? 
A type of post-transcriptional modification where AA arginine is converted into AA citrulline
What enzyme mediates the citrullination of peptides?
Peptidyl arginine deiminases
Why is the presence of CCP a useful marker of RA?
It’s highly specific, hence if you have it you are very likely to have rheumatoid arthritis
What 3 imaging techniques can you do in RA?
X-ray
Ultrasound
MRI
How useful are X rays in diagnosing RA?
Can only see severe forms of RA with X Ray
Harder to pick up early stages of RA
How useful is an ultrasound detecting rheumatoid arthritis?
V good at picking up earlier stages of condition
Can see:
Synovial hypertrophy, Increased blood flow and erosions
What is a Doppler signal and how does this relate to RA?
Shows blood flow through tissue during ultrasound. Seen in early stages of RA
What are the 3 main groups of medication RA patients can use?
Glucocorticoids (steroids)
NSAIDs
DMARDS (disease modifying anti rheumatic drugs)
Why are steroids used in rheumatoid arthritis?
Reduce inflammation but only used in short term
Why are steroids only used in the short term and what major condition can it lead to?
Have really bad side effects such as Cushing syndrome
What is the 1st line treatment regime of RA
short course of steroids
DMARD (methotrexate & another one)
What is the main DMARD used in RA?
methotrexate
How does methotrexate work?
Inhibits dihydrofolate reductase
Is immunosuppressive
What is the 2nd line treatment regime for RA
biologicals such as anti-TNF-a
What do DMARDS tend to be
Immunosuppressive
What are biological therapies?
Proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine
What are 4 things biological therapies can target to treat RA?
- Inhibit TNF-a
- Deplete B cell
- Modulation of T cell costimulation
- Inhibit IL-6 signalling
What does the ‘seronegative’ mean in seronegative arthritis?
Blood doesn’t have rheumatoid factor or CCP, but patient still has arthritis
What is psoriatic athritis?
Arthritis that occurs when you have psoriasis
Is rheumatoid factor present in psoriatic arthritis?
No - it’s a seronegative arthritis
What are some of the clinical presentations of psoriatic arthritis?
Varied clinical presentations, but classically asymmetrical arthritis affecting interphalangeal joints
What is reactive arthritis?
Sterile inflammation in joints following infection elsewhere in the body
What are the common infections that cause reactive arthritis?
Urogenital
Gastrointestinal
HIV
Hep C
What are some important extra-articular manifestations of reactive arthritis?
Enthesitis (tendon inflammation)
Skin inflammation
Eye inflammation
What type of arthritis is seen as a manifestation of HIV or HEP C infection?
Reactive arthritis
Which HLA makes you more predisposed to reactive arthritis?
HLA -B27
How long after infection does reactive arthritis symptoms begin to show?
1-4 weeks post infection
What is inflammatory spondyloarthritis?
Inflammation of spine and sacroiliac joints
Peripheral joints such as entheses an also be affected
What is a classical example of inflammatory spondyloarthritis?
Ankylosing spondylitis
What are the the extra articular manifestations of inflammatory spondyloarthritis? (4 A’s)
Anterior uveitis
Apical lung fibrosis
Aortitis
Amyloidosis
What does this image show and which type of arthritis is this seen in?
Anterior uveitis
Seen in inflammatory spondyloarthritis
What is ankylosing spondylitis characterised by?
Enthesitis (inflammation of the entheses - where tendon/ligament join to bone)
Which HLA gene is strongly associated with ankylosing spondylitis?
HLA-B27
What 3 cytokines have a key role in the pathophysiology of ankylosing spondylitis?
TNF-A
IL-17
IL-23
What is a key clinical feature of ankylosing spondylitis?
Loss of spinal movement
What happens if ankylosing spondylitis is left untreated
Spinal Enthesitis -> bone growths between vertebrae -> spinal fusion -> loss of spinal movement
What sign does this MRI show and what condition is this ?
Shiny corners - seen in ankylosing spondylitis
How is ankylosing spondylitis managed?
Combination of physiotherapy and
Pharmolologicals
What are the 1st line drugs used in ankylosing spondylitis?
NSAIDS
what is the mechanism of action of NSAIDS
inhibits COX 1 &2 hence inhibits prostaglandin production, reducing inflammation and pain
What are some key side effects of NSAIDS
Peptic ulcers and asthma exacerbation
Why is asthma exacerbated by NSAIDS.?
As NSAIDs inhibit conversation of arachidonic acid into prostaglandins, more arachidonic acid is converted into leukotrienes which causes bronchoconstriction
What is the 2nd line treatment option for ankylosing spondylitis?
Biological therapies
What are the biological therapies used in treating ankylosing spondylitis ?
Monoclonal antibodies
Anti-TNF-A
Anti-IL17
What is lupus (sle)
A multi-system autoimmune disease
Which organ is particularly affected by SLE?
Kidneys, leads to renal failure
What clinical tests can be used to diagnose SLE
usually detect autoantibodies such as:
Antinuclear antibodies
Anti double stranded DNA antibodies
What type of rash is this and in which condition do you commonly see this in?
Malar/ butterfly rash seen in SLE
