Johnston: Rheumatoid Arthritis Flashcards
1
Q
Systemic features of RA
A
- fatigue, fever, anemia
- elevated ESR and CRP
- Malaise, myalgia, depression
2
Q
What is RF produced by?
A
- RA synovium
- made by B cells
3
Q
What do RF’s do?
A
-fix complement
4
Q
What does complement consumed in RA joint do?
A
-recruits PMN’s
5
Q
What is the more specific antibody in RA?
A
-Anti Cyclic citrullinated peptides
6
Q
What two lab tests would be most diagnostic for RA?
A
- RF
- Anti CCP
7
Q
What imaging would we do for RA?
A
- X rays of the hands and ffet
- CT is more sensitive detecting erosions
8
Q
Tx for RA
A
- Begin NSAID for pain control
- Early use of DMARD
- may need low dose of steroid for a few weeks
- monitor progress and toxicity
9
Q
when does RA improve?
A
-during preggo
10
Q
What age does RA happen at?
A
-young adults
11
Q
in the point system for RA, what kinds of joints give the patient a lot of points towards having RA?
A
-small joints
12
Q
What is the only part of the axial spine that really gets affected by RA?
A
-C1 and C2
13
Q
What part of the hand will almost never be involved with RA?
A
- the PIP
14
Q
Swan neck
A
-hyperextension of PIP joints
15
Q
Boutonnier
A
-hyperflexion of PIP joints
16
Q
What might we find on the extensor surface of the forearm with RA?
A
-a nodule
17
Q
What will that nodule on the extensor surface almost always be positive for?
A
-RF!
18
Q
What will we see in the wrist?
A
- radial deviation
- ulnar deviation of the fingers
19
Q
What will we see in the knees?
A
- bakers cyst
- popliteal…. may rupture and be painful
20
Q
What will we see in the neck?
A
-C1-2 subluxation… dont force into flexion
21
Q
Clinical manifestations of RA
A
- pain, swelling, warmth in multiple small joints of the hands and feet
- morning stiffness> one year
- > 10% have abrupt onset of disease
22
Q
extraarticular manifestations of RA
A
- subQ nodules on extensor surface of forearm
- more common in RF positive or anti-CCP positive
23
Q
What is Pyroderma gangrenosum
A
- tender reddish purple papule
- leads to necrotic, non healing ulcer
- lower extremity
- poor prognosis
24
Q
Rheumatoid Vasculitis
A
- purpura, petechial splinter hemorrhages
- digital infarct
25
Heart in RA
- RA is an independent risk factor for CAD
| - HF, pericarditis, CAD due to chronic endothelial inflammation
26
What is it called when someone has nodular opacities on their lung x ray from a rheumatoid nodule?
-caplan syndrome
27
What will we see if there is interstitial lung disease?
-clubbing
28
most common thing with lung
-pleuritis
29
What is caplan syndrome
-nodular densities after exposure to coal or silica dust
30
When treating someone for RA, what is something that could happen to the patient that would give them keratoconjunctivitis sicca?
-Secondary Sjogrens syndrome
31
What antibodies are associated with salivary gland involvement
-Ro and La
32
What is schirmers test?
-when you take a piece of filter paper and put it under their eyelid to see if they will make tears or not
33
How do you treat sjogren's?
- artificial tears
| - remember that sjogrens syndrome is seen in 35% of RA patients
34
What is the most common manifestation of RA involving the eyes?
-keratoconjunctivitis sicca secondary to Sjogrens syndrome
35
Sjogrens syndrome
- dry everythings
- primary Sjogrens is associated with SS-A (Ro) and SS-B (La) antibodies
- treat symptoms
- anti inflammatory and immunosuppressive
36
Feltys Syndrome
- RA
- splenomagalia
- Neutropenia
- Fever
- Anemia
- Thrombocytopenia
- RF and anti-CCP positive
37
What happens in RA due to erosion of odontoid process?
- antlantoaxial subluxation
| - peripheral neuropathy will result
38
Diagnosis of RA
-No single finding on physical exam or lab tests that is pathognomonic
39
Lab findings for RA
- RF positive
- anti CCP antibody
- Increased ESR, CRP
- Anemia
- Thrombocytosis
- Low glucose in body fluids
40
Tx of RA
- no known cure
- Use consultant, PT, OT
- Articular rest
- Treat to target
- Goal is disease remission; possible in 50% of patients if treated early
41
NSAID
- pain relief
- does not halt disease progression
- can use with DMARD's
- GI toxicity
- Inhibits COX enzymes/ PGE2, promotes renal sodium exertion
42
Corticosteroids
- use in low doses
- can use with DMARD
- Bridge Therapy
- chronic use many side-effects
43
DMARDs
- Disease modifying anti-rhematic drugs
- immunosuppressive agent; increase risk of infection
- use first to minimize damage
- can halt disease progression in synovium and halt/slow radiographic progression
- takes 2 to 6 months to exert maximal effect
44
What does Methotrexate do?
- inhibits folic acid
- recommended as first DMARD for RA/once a week
- useful in PsA
45
Toxicity for methotrexate
-hepatic, myelosuppression, pulmonary
46
when do we not give MTX?
-during pregnancy
47
What are the antimalarial agents we can use?
- Hydroxychoroquine
- need F/U with ophthalmologist
- can use with MTX and sulfasal
- Safe in preggo pts
- Useful in RA
48
Leflunomide
- pyrimidine antagonist
- rapid excretion with cholestyramine
- DONT USE WHEN PREGNANT
- GI/hepatic toxicity/teratogenic
49
Sulfasalazine
- Effective in RA
- Monitor WBC
- Can use with MTX
- Safe in those who are pregnant
50
What the toxicities of all biologics?
- Increased risk of infection
- reactivation of latent TB
- Neoplasia
- MS
- Autoimmune disease
51
TNF
- pro inflammatory cytokine in RA pathogenesis
- stimulates synovial cell proliferation and collagenase/ destroy cartilage
- Increase inflammation
52
Anti TNF agents
- Etanercept
- Infliximab
- Adalimumab
- rituximab
53
Managing RA
- define extent of joint and extra-articular involvement
- full dose of NSAID
- Early use of DMARD
- Add a biologic agent
- low dose steroids
- adequate pain management
- monitor progress/toxicity
54
What are the spondyloarthropies (SpA)
- Ankylosing spondylitis
- Reactive Arthritis
- Psoriatic Arthritis
- Enteropathic arthritis (EA)
- Undifferentiaed : doesn't fit into diagnostic categories, but shares clinical features
55
Where do seronegative spondyloarthropaties usually happen?
-the spine, SI joints
56
What is enthesitis?
- inflammed tendon insertion into bone
| - immune susceptibility to Allele B27
57
What is spondylitis
-inflammation of vertebrae
| -
58
what is spondylolisthesis
-anterior displacement of a vertebral body relative to the adjacent vertebral body below
59
what si spondylolysis
-defect of the portion of bone between the inferior and superior articular process of vertebrae
60
What is reactive arthritis formerly known as ?
-Reiter's syndrome
61
What are spondyloarthropathies?
- rheumatic disorders
- axial skeleton, peripheral joints
- HLA B27 assocated with extra-articular manifestations
62
What are the big spondyloarthropathies that are associated with HLA B27?
-Ankylosing spondylitis and Reactive Arthritis
63
If you think someone has ankylosing spondylitis, what do you test for?
-HLA B27
64
Ankylosing spondylitis
- HLA B27
- most common inflammatory disorder of axial skeleton
- 2nd and 3rd decade so pretty young!
65
clinical manifestations of ankylosing spondylitis
- low back pain>3 months
- morning stiffness, improved with exercise, worse with rest
- fatigue, weight loss, and fever
- symmetrical SI joint pain, loss of mobility/flexibility; arthritis of hips
- tendonitis, plantar fasciitis/enthesitis
66
what is that extraarticular finding that we see in AS but not in RA?
- Iritis is not found in RA,
| - can find iritis in SLE, herpes simplex
67
Physical exam with AS?
- restricted forward flexion and restricted chest expansion (FABERE test
- if inhalation doesn't change 5cm, that is restriction
68
labs for AS
- Increase ESR, CRP,
- HLA B27
- Anemia of chronic disease
- Negative RF, ACCP, ANA*
69
Imaging for AS
- AP radiographs of pelvis; bl SI changes
- erosions of SI joints, psueod sidening, sclerosis, fuses, ankyloses, symmetric
- Vertebrae will have squaring and shiny corners; sclerosis at edge of vertebral bodies
70
What are syndesmophytes?
- bridging of vertebrae (boney bridges cause ankylosis
| - this is freaking BAMBOO SPINE
71
What imaging modality is more sensitive for erosions?
- CT
| - MRI detects inflammation before changes seen on S rays or CT though
72
What are some late complications of AS?
-restrictive lung disease, compression fractures, cauda equina syndrome
73
What were the key points for AS
- back pain before 40
- insidious onset
- >3months
- AM stiffness, reduction in spinal mobility
- improvement with exercise or activity
- positive family hx
74
Tx of AS
- exercise!!!
- NSAID
- TNF inhibitors
- Non biologics like MTX is good for peripheral arthritis, but not for axial disease
75
Reactive Arthritis
- AI disease
- asymmetric mono-arthritis or oligo-arthritis in lower extremities
- may be associated with infection
- GI: salmonella, shigella, tersinia, campylobacter jejuni
- GU: Chlamydia trachomatis
- HLA B27 is present in 75% of ReA and IBD associated arthritis
76
Clinical manifestations of ReA in young men
- arthritis that is asymmetrical, lower extremities (ankles, knees)
- Enthesitis: achilles tendon/ Plantar fasciitis
- Dactylitis: sausage digit; finger or toe
77
What is Reiter's syndrome
- cant see, pee, climb a tree
| - Urethritis, arthritis, conjunctivitis, mucocutaneous lesions
78
What might we see on the penis of a man who has reactive arthritis?
- circinate balanitis
| - right on the tip... ouch
79
What is Keratoderma blennorrhagica?
- painless eruptions on the feet
| - can happen with Reiter's syndrome
80
What will imaging look like for ReA?
SI joint
| -asymmetrical
81
Labs for ReA
- same as for AS
| - HLA B27
82
ReA tx
- self limited in 6 months
- NSAID
- If chronic progression, use DMARD
- Urethritis; chlamydia, azithromycin or doxycycline
83
Psoratic Arthritis (PsA)
- peak age 40-60
- presents in 5-20% of pts with psoriasis
- associated with SI and axial involvement
84
Peripheral arthritis
- may be asymmetric or symmetrical
- DIP, PIP, MCP, MTP
- pitting nails
- Bactylitis and enthesitis
- may have V1-2
- PsA flare up may be due to co infection with HIV
85
Which kind of arthritis gave us the pencil in a cup thing on radiograph?
-Psoriatic arthritis
86
Enteropathic ARthritis
- arthritis associated with CD or UC
- axial involvement
- peripheral arthritis
- all extra-articular manifestations occur more commonly in CD
87
Extra articular manifestations of EA
- Pyoderma gangrenosum, erythema nodosum
- Uveitis
- CD/UC
- Nephrolithiasis
- Thromboembolism
- bone fracture, low bone density
88
What are the basic treatment for SpA
- exercise
- NSAID
- Gucocorticoids
- MTX: only works for peripheral arthritis, not Axial
- Sulfasalazine- PsA
- DMARD's - PsA
- Antibiotics- Chlamydia urethritis
