ORTHO 224 Rheumatoid Arthritis

Question 1

Rheumatoid arthritis

Answer 1

Chronic systemic inflammatory disorder primarily affecting the synovium due to autoantibodies against IgG and CCP

Question 2

What is the pathology behind RA?

Answer 2

There is synovial inflammation leading to hyperplasia with inflammatory and vascular infiltration = Pannus formation
This causes damage to the underlying cartilage by blocking the normal route of nutrition for the joint

Question 3

What are the major cell types in the Pannus of RA?

Answer 3

T-lymphocytes and macrophages

Question 4

What leads to deformities in RA?

Answer 4

bone exposure and erosions

Question 5

How does RA present?

Answer 5

Slow symmetrical progression of a peripheral monoarthritis - usually between 30-50 years of age
More common in females than males

Question 6

What are the early indications of RA?

Answer 6

pain and stiffness in the small hand and foot joints - worse in the morning
fatigue is a very common complaint
eventual restriction in movement

Question 7

What can you see in RA hands?

Answer 7

ulnar deviation at the MCP joints
fixed flexion (boutanniere?) or fixed extension (swan neck deformity)

Question 8

What can you see in RA shoulder?

Answer 8

mimic of rotator cuff tendonitis

Question 9

What can happen in RA feet?

Answer 9

swelling of MTP joints, broader feet and hammer toes with flat medial arch

Question 10

What extra articular features can you have in RA?

Answer 10

nodules, vasculitis, lung (effusion/fibrosis/bronchiectasis), Heart (pericarditis, valvular disease); eyes (episcleritis/keratoconjunctivitis); Neuro (entrapment neuropathies); Haem (anaemia, thrombocytosis)

Question 11

What are the 5 steps of treatment for RA?

Answer 11

Analgesia
NSAIDS
Corticosteroids
DMARDs
Biological agents

Question 12

What NSAIDs are commonly used in RA?

Answer 12

ibuprofen, diclofenac and naproxen

Question 13

What DMARD’s are used in RA?

Answer 13

methotrexate (+folic acid) : oral/subcut, once a week

sulfasalazine: daily, oral
leflunomide: daily, oral, a pyrimidine synthesis inhibitor

Question 14

What are the monoclonal ab drugs used in RA?

Answer 14

infliximab - (chimeric)
adalimumab (human)
certolizumab (humanized)
entacerecept (fusion protein) - acts on soluble receptor protein

Question 15

What is rituximab

Answer 15

A new cytokine modulate = lysis of CD20 B cells

= significant improvement in RF+ve RA

Question 16

What is a vasculitis?

Answer 16

Inflammation within or through a vessel wall leading to impairment of blood flow and sometimes damage to vessel integrity = haemorrhage and organ infarct

Question 17

What is Polymyalgia Rheumatica?

Answer 17

Sudden onset of severe pain and stiffness in the neck, shoulders, hip and lumbar spine
Worse in the morning and improves with activity
Between 50-60years
Malaise, weight loss
ESR >60 and raised CRP
Dramatic response to small dose corticosteroid

Question 18

Describe Giant Cell Arteritis

Answer 18

Vasculitis commonly accompanying PMR
Affects large vessels - arch of aorta & branches
severe headaches, jaw claudication, fatigue, visual disturbances
Can lead to MI, stroke, blindness and tissue necrosis
Tx with high dose prednisolone

Question 19

Describe Wegners Granulomatosis

Answer 19

Destructive vasculitis involving midline structures (ELK)
ENT, lungs and kidneys but also: skin and eyes
ENT most common presentation: sinusitis, otitis media, discharge
Lungs: Haemoptysis, SOB, pleuritis

Associated with ANCA antibodies

Question 20

Describe polyarteritis nodosa

Answer 20

Rare condition
Middle aged men
multi-system vasculitis
aneurysm formation in medium sized vessels
constitutional symptoms, mononeuritis multiplex, HTN, GI infarct/necrosis, testicular pain, haematuria

Question 21

How generally do you treat a vasculitis?

Answer 21

Inducing remission: steroids, cyclophosphamide, biologics
Maintain remission: azathioprine, methotrexate, mycophenolate, biologics
Monitor

Question 22

Describe SLE?

Answer 22

Connective tissue disease
F>M (9:1) between 20&40 years
arthralgia, rash, constitutional sx, ulcers, myalgia, raynauds and a whole HOST of problems
ANA/ANF if -ve rule out SLE
dsDNA ab’s specific for SLE but only in 50%
variety of other ab’s

Manage: hydoxycloroquine for joints, steroids for severe systemic disease and iv cyclophosphamide for renal/late stage

Question 23

Describe scleroderma

Answer 23

Connective tissue disease
hard skin, localised or systemic
CREST syndrome: Calcinosis, Raynauds, Eosophagus, sclerodactyly, telengectasia
Vascular complications