Johnston: Rheumatoid Arthritis Flashcards
Systemic features of RA
- fatigue, fever, anemia
- elevated ESR and CRP
- Malaise, myalgia, depression
What is RF produced by?
- RA synovium
- made by B cells
What do RF’s do?
-fix complement
What does complement consumed in RA joint do?
-recruits PMN’s
What is the more specific antibody in RA?
-Anti Cyclic citrullinated peptides
What two lab tests would be most diagnostic for RA?
- RF
- Anti CCP
What imaging would we do for RA?
- X rays of the hands and ffet
- CT is more sensitive detecting erosions
Tx for RA
- Begin NSAID for pain control
- Early use of DMARD
- may need low dose of steroid for a few weeks
- monitor progress and toxicity
when does RA improve?
-during preggo
What age does RA happen at?
-young adults
in the point system for RA, what kinds of joints give the patient a lot of points towards having RA?
-small joints
What is the only part of the axial spine that really gets affected by RA?
-C1 and C2
What part of the hand will almost never be involved with RA?
- the PIP
Swan neck
-hyperextension of PIP joints
Boutonnier
-hyperflexion of PIP joints
What might we find on the extensor surface of the forearm with RA?
-a nodule
What will that nodule on the extensor surface almost always be positive for?
-RF!
What will we see in the wrist?
- radial deviation
- ulnar deviation of the fingers
What will we see in the knees?
- bakers cyst
- popliteal…. may rupture and be painful
What will we see in the neck?
-C1-2 subluxation… dont force into flexion
Clinical manifestations of RA
- pain, swelling, warmth in multiple small joints of the hands and feet
- morning stiffness> one year
- > 10% have abrupt onset of disease
extraarticular manifestations of RA
- subQ nodules on extensor surface of forearm
- more common in RF positive or anti-CCP positive
What is Pyroderma gangrenosum
- tender reddish purple papule
- leads to necrotic, non healing ulcer
- lower extremity
- poor prognosis
Rheumatoid Vasculitis
- purpura, petechial splinter hemorrhages
- digital infarct
Heart in RA
- RA is an independent risk factor for CAD
- HF, pericarditis, CAD due to chronic endothelial inflammation
What is it called when someone has nodular opacities on their lung x ray from a rheumatoid nodule?
-caplan syndrome
What will we see if there is interstitial lung disease?
-clubbing
most common thing with lung
-pleuritis
What is caplan syndrome
-nodular densities after exposure to coal or silica dust
When treating someone for RA, what is something that could happen to the patient that would give them keratoconjunctivitis sicca?
-Secondary Sjogrens syndrome
What antibodies are associated with salivary gland involvement
-Ro and La
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
How do you treat sjogren’s?
- artificial tears
- remember that sjogrens syndrome is seen in 35% of RA patients
What is the most common manifestation of RA involving the eyes?
-keratoconjunctivitis sicca secondary to Sjogrens syndrome
Sjogrens syndrome
- dry everythings
- primary Sjogrens is associated with SS-A (Ro) and SS-B (La) antibodies
- treat symptoms
- anti inflammatory and immunosuppressive
Feltys Syndrome
- RA
- splenomagalia
- Neutropenia
- Fever
- Anemia
- Thrombocytopenia
- RF and anti-CCP positive
What happens in RA due to erosion of odontoid process?
- antlantoaxial subluxation
- peripheral neuropathy will result
Diagnosis of RA
-No single finding on physical exam or lab tests that is pathognomonic
Lab findings for RA
- RF positive
- anti CCP antibody
- Increased ESR, CRP
- Anemia
- Thrombocytosis
- Low glucose in body fluids
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
NSAID
- pain relief
- does not halt disease progression
- can use with DMARD’s
- GI toxicity
- Inhibits COX enzymes/ PGE2, promotes renal sodium exertion
Corticosteroids
- use in low doses
- can use with DMARD
- Bridge Therapy
- chronic use many side-effects
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
What does Methotrexate do?
- inhibits folic acid
- recommended as first DMARD for RA/once a week
- useful in PsA
Toxicity for methotrexate
-hepatic, myelosuppression, pulmonary
when do we not give MTX?
-during pregnancy
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
Leflunomide
- pyrimidine antagonist
- rapid excretion with cholestyramine
- DONT USE WHEN PREGNANT
- GI/hepatic toxicity/teratogenic
Sulfasalazine
- Effective in RA
- Monitor WBC
- Can use with MTX
- Safe in those who are pregnant
What the toxicities of all biologics?
- Increased risk of infection
- reactivation of latent TB
- Neoplasia
- MS
- Autoimmune disease
TNF
- pro inflammatory cytokine in RA pathogenesis
- stimulates synovial cell proliferation and collagenase/ destroy cartilage
- Increase inflammation
Anti TNF agents
- Etanercept
- Infliximab
- Adalimumab
- rituximab
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
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
Where do seronegative spondyloarthropaties usually happen?
-the spine, SI joints
What is enthesitis?
- inflammed tendon insertion into bone
- immune susceptibility to Allele B27
What is spondylitis
-inflammation of vertebrae
-
what is spondylolisthesis
-anterior displacement of a vertebral body relative to the adjacent vertebral body below
what si spondylolysis
-defect of the portion of bone between the inferior and superior articular process of vertebrae
What is reactive arthritis formerly known as ?
-Reiter’s syndrome
What are spondyloarthropathies?
- rheumatic disorders
- axial skeleton, peripheral joints
- HLA B27 assocated with extra-articular manifestations
What are the big spondyloarthropathies that are associated with HLA B27?
-Ankylosing spondylitis and Reactive Arthritis
If you think someone has ankylosing spondylitis, what do you test for?
-HLA B27
Ankylosing spondylitis
- HLA B27
- most common inflammatory disorder of axial skeleton
- 2nd and 3rd decade so pretty young!
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
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
Physical exam with AS?
- restricted forward flexion and restricted chest expansion (FABERE test
- if inhalation doesn’t change 5cm, that is restriction
labs for AS
- Increase ESR, CRP,
- HLA B27
- Anemia of chronic disease
- Negative RF, ACCP, ANA*
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
What are syndesmophytes?
- bridging of vertebrae (boney bridges cause ankylosis
- this is freaking BAMBOO SPINE
What imaging modality is more sensitive for erosions?
- CT
- MRI detects inflammation before changes seen on S rays or CT though
What are some late complications of AS?
-restrictive lung disease, compression fractures, cauda equina syndrome
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
Tx of AS
- exercise!!!
- NSAID
- TNF inhibitors
- Non biologics like MTX is good for peripheral arthritis, but not for axial disease
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
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
What is Reiter’s syndrome
- cant see, pee, climb a tree
- Urethritis, arthritis, conjunctivitis, mucocutaneous lesions
What might we see on the penis of a man who has reactive arthritis?
- circinate balanitis
- right on the tip… ouch
What is Keratoderma blennorrhagica?
- painless eruptions on the feet
- can happen with Reiter’s syndrome
What will imaging look like for ReA?
SI joint
-asymmetrical
Labs for ReA
- same as for AS
- HLA B27
ReA tx
- self limited in 6 months
- NSAID
- If chronic progression, use DMARD
- Urethritis; chlamydia, azithromycin or doxycycline
Psoratic Arthritis (PsA)
- peak age 40-60
- presents in 5-20% of pts with psoriasis
- associated with SI and axial involvement
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
Which kind of arthritis gave us the pencil in a cup thing on radiograph?
-Psoriatic arthritis
Enteropathic ARthritis
- arthritis associated with CD or UC
- axial involvement
- peripheral arthritis
- all extra-articular manifestations occur more commonly in CD
Extra articular manifestations of EA
- Pyoderma gangrenosum, erythema nodosum
- Uveitis
- CD/UC
- Nephrolithiasis
- Thromboembolism
- bone fracture, low bone density
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
