Presentation of Rheumatoid Arthritis

Question 1

What is the Epidemiology of RA

Answer 1

Approx. 1% of population ie approx. 4000 cases in Grampian F:M – 3:1 Age of onset – 4th/5th decade but may occur any age from 16 years on

Question 2

What does RA typically present with

Answer 2

It typically presents with a symmetrical distal polyarthropathy with Pain Swelling Stiffness

Question 3

What joints of the body are typically affected in RA

Answer 3

Proximal Interphalangeal Joints (PIP) joints Metacarpophalangeal (MCP) joints Wrist and ankle Metatarsophalangeal joints Cervical spine Large joints can also be affected such as the knee, hips and shoulders

Question 4

What joints are almost never affected by rheumatoid arthritis.

Answer 4

The distal interphalangeal joints If you come across enlarged painful distal interphalangeal joints this is most likely to be Heberden’s nodes due to osteoarthritis.

Question 5

What are systematic symptoms that present in RA

Answer 5

Fatigue

Weight loss

Flu like illness

Muscles aches and weakness

Question 6

What is Palindromic Rheumatism

Answer 6

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.

Question 7

What spinal condition can be a presentation of RA

Answer 7

Atlantoaxial Subluxation

Question 8

What is Atlantoaxial Subluxation

Answer 8

Atlantoaxial subluxation occurs in the cervical spine. The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas

Question 9

Why is Atlantoaxial Subluxation bad/dangerous

Answer 9

Subluxation can cause spinal cord compression and is an emergency. This is particularly important if the patient is having a general anaesthetic and requiring intubation. MRI scans can visualise changes in these areas as part of pre-operative assessment.

Question 10

What are specific signs in the hands of RA

Answer 10

Z shaped deformity to the thumb

Swan neck deformity

Boutonnieres deformity

Ulnar deviation of the fingers at the knuckle

Question 11

What is Swan neck deformity

Answer 11

Hyperextended PIP with flexed DIP)

Question 12

What is Boutonnieres deformity

Answer 12

Hyperextended DIP with flexed PIP

Question 13

What are Extraarticular Manifestations of RA (X11)

Answer 13

Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)

Bronchiolitis obliterans (inflammation causing small airway destruction)

Felty’s syndrome (RA, neutropenia and splenomegaly)

Secondary Sjogren’s Syndrome (AKA sicca syndrome)

Anaemia of chronic disease

Cardiovascular disease

Episcleritis and scleritis

Rheumatoid nodules

Lymphadenopathy

Carpel tunnel syndrome Amyloidosis

Question 14

What are investigations for RA

Answer 14

Check rheumatoid factor

Inflammatory markers such as CRP and ESR

X-ray of hands and feet

Ultrasound

Question 15

What do you check If RF is negative

Answer 15

Check anti-CCP antibodies

Question 16

What is ultrasound useful for in RA investigation

Answer 16

Ultrasound scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.

Question 17

What X-ray changes might be seen in RA

Answer 17

Joint destruction and deformity

Soft tissue swelling

Periarticular osteopenia

Boney erosions

Question 18

How do you measure disease activity in RA

Answer 18

Disease activity score

Question 19

What is the Disease activity score (DAS)

Answer 19

It is based on the assessment for 28 joints and points are given for: Swollen joints Tender joints ESR/CRP result

Question 20

What does a DAS <2.4 represent

Answer 20

Clinical remission

Question 21

What does a DAS >5.1 represent

Answer 21

Eligibility for biological therapy