Lanigan Rheumatoid Arthritis Flashcards
A 34 y/o day care attendant is seen after 4 weeks of polyarthritis of the wrists and knees. RA latex is low positive, and ESR is normal. She is diagnosed with RA and started on low dose MTX. Which is true?
A – A positive anti- CCP will confirm the diagnosis.
B – X-ray or ultrasound may confirm the diagnosis.
C – Treatment should always start with NSAIDs.
D – CRP should be done before starting MTX.
E – She probably has an alternative diagnosis.
E- probably an alternative diagnosis (parvovirus B19?)
Classification criteria for RA
Over 6 points is definite RA.
1 large joint- 0 points 2-10 large ones- 1 1-3 small ones - 2 4-10 small ones - 3 > 10 joints with at least one small- 5
Serology:
Negative- o
low positive RF OR low positive ACPA- 2
high positive RF or ACPA- 3
Symptom duration
less than 6 weeks - 0
more- 1
Acute phase reactants
Normal CRP AND normal ESR- 0
Abnormal either one- 1
What if RA score is less than 6?
Patient might fulfill the criteria…
–> prospectively over time (cumulatively)
–> restrospectively if data on all 4 domains have been adequately recorded in the past
ACPA is what?
Anti-CCP Ab
Rheumatoid Arthritis
Symmetric inflammatory polyarthritis. Typical affected joints: PIP, MCP, wrists. Morning stiffness >60 minutes. Affects ~1% of the population. Female-to-male ratio 2-3:1. Peak incidence at age 30-60.
Pathogenesis
An external trigger sets off an autoimmune rxn → synovial hypertrophy and chronic joint inflammation in genetically susceptible individuals.
Genetics – there are >20 risk alleles; strongest association is with HLA-DRB1.
Autoantibodies – RF, anti-CCP Ab.
Environmental factors – smoking, occupational exposures (silica, asbestos, carpentry).
Infection – periodontal disease with Porphyromonas gingivalis.
strongest risk allele
HLA DRB-1
factors in RA development
multiple susceptibility genes
Environment- smoking, periodontal infection
Carbamylation, citrullination
Anti-CarP
ACPA
Arthralgia
Arthritis
RA
Pathology of RA
Synovial cell hyperplasia and endothelial cell activation are seen in early RA.
CD4 T cells, mononuclear phagocytes, fibroblasts, osteoclasts, and neutrophils, and B cells (RF) play major roles. Cytokines, chemokines, and other inflammatory mediators (eg, TNF-a, interleukin IL-1, IL-6, IL-8, TGF-ß, FGF, PDGF) are all active.
Ultimately, inflammation and exuberant proliferation of the synovium (ie, pannus) leads to destruction of cartilage, bone, tendons, ligaments, and blood vessels.
Destruction of the cartilage and erosion of the underlying bone with pannus from a patient with rheumatoid arthritis.
A 35 y/o female presents with numbness in the right thumb and index finger over the past 6 months which she attributes to typing at work. Closer questioning reveals a 3 month history of PIP and MCP swelling and tenderness of the 2nd, 3rd, and 4th digits of the right hand, and the MCP joints of the 2nd and 3rd digits of the left hand, associated with 30-60 minutes of morning stiffness. She also reports stiffness in the first metatarsal joint of each foot. She does not smoke or drink alcohol and loves to garden in her spare time.
What are some causes of numbness in the thumb and index finger?
“MEDIAN TRAP” Myxedema Edema Diabetes Infiltration (sarcoid, leukemia, fibrosis) Amyloid Neoplasms
Trauma
RA
Acromegaly
Pregnancy
Upon examination, the patient is found to have a “doughy or spongy” feeling of her PIP and MCP joints with an exquisitely tender 2nd MCP joint of the left hand. The latter joint feels warmer than the other joints and provokes pain with motion. What should be done next?
Joint aspiration is done.
No organisms are seen on Gram stain, and culture comes back negative.
Describe the differential diagnosis of symmetric polyarthritis.
OA
RA
Other forms of arthritis
- Gout
- Spondyloarthropathies
- Lyme arthritis
- FMF
Infections
- Parvo B 19
- Hepatitis C
Collagen Vascular diseases
- SLE
- Polymyalgia rheumatica
- Wegeners
- RF
Cancers
- Hypertrophic pulmonary osteoarthropathies – lung and - GI cancers
- Palmar fasciitis – ovarian carcinoma
Skin changes in RA
Rheumatoid nodules = RF seropositivity!
Pts. With rheumatoid nodules are more likely to have anti-CCP, and vasculitis.
can also see nodules in the sclera and lungs
Acute Febrile Neutrophilic Dermatosis
(Sweet syndrome)
Fever Fatigue Skin lesions Sore eyes Mouth ulcers
clears up with steroids
not just seen in RA, also some cancers etc.
when do we see Pyoderma Gangrenosum
Seen in RA, Crohn’s, ulcerative colitis, and IgA myeloma.
Skin changes (vascular) in RA
Livedo reticularis -
medium vessel vasculitis
Small vessel vasculitis – circular purpura
Pulmonary Involvement
Pulmonary causes are a significant contributor to excess mortality in patients with RA!
Pleuritis is common (usually asymptomatic).
Exudative pleural effusions may be seen.
Rheumatoid nodules in lungs.
- Peripheral, usually <1 cm.
Interstitial lung disease with fibrosis.
- More common in smokers, highly seropositive pts., males.
↑ Prevalence of COPD.
PE findings with rheumatoid nodules in lung
Cough
Dyspnea
“Cellophane crackles” – close to the ear crackles
Caplan syndrome
Although rare, rheumatoid pneumoconiosis, aka Caplan syndrome, occurs only in pts with both RA and pneumoconiosis related to mining dust (coal, asbestos, silica).
Symptoms: cough, dyspnea, wheeze, joint pain and swelling.
Cardiac Involvement
CHF contributes to ↑ mortality in RA. ↑ Risk for cardiovascular disease. - May be due to chronic inflammation. Pericarditis - Most common in males with severely destructive and nodular RA. RA-associated cardiomyopathy Coronary vasculitis
Cervical Spine Involvement
Abnormalities of the cervical spine in RA:
- Atlantoaxial instability / atlantoaxial subluxation.
- Superior migration of the odontoid.
- Subaxial subluxation
Eye Involvement
Scleritis may be seen in RA as part of the Sicca Syndrome with keratoconjunctivitis sicca.
Scleromalacia perforans is degenerative thinning of the sclera, seen in RA.
Felty’s syndrome
Make sure to do ab exam on RA pt!
SANTA
Splenomegaly Anemia Neutropenia, Nodules Thrombocytopenia Arthritis (Rhematoid)
75% of Felty’s syndrome patients have rheumatoid nodules.
What labs and imaging would you order if you suspect RA?
Anti-CCP
