RA Flashcards
- chronic inflammatory disease of unknown etiology characterized by a symmetric polyarthritis
- results in articular cartilage and bone destruction and functional disability
Rheumatoid Arthritis
are routinely included with rheumatoid factor in the diagnostic evaluation of patients
Serum antibodies to cyclic citrullinated peptides (anti-CCPs)
CLINICAL FEATURES
- incidence increases between 25 and 55 years of age
- plateaus until the age of 75 and then decreases
- early morning joint stiffness lasting more than 1 h that eases with physical activity
- earliest involved joints are typically the small joints of the hands and feet
Initial pattern of joint involvement of RA may be:
- monoarticular, oligoarticular (<4 joints),
- polyarticular (>5 joints)
- symmetric distribution
patients with inflammatory arthritis who present with too few affected joints to be classified as having RA
undifferentiated inflammatory arthritis
an undifferentiated arthritis who are most likely to be diagnosed later with RA have
- higher number of tender and swollen joints
- positive for serum rheumatoid factor or anti-CCP antibodies
- high scores for physical disability
an undifferentiated arthritis who are most likely to be diagnosed later with RA have
Flexor tendon tenosynovitis
Most frequently involved joints of RA:
- Wrists
- metacarpophalangeal (MCP)
- proximal interphalangeal (PIP) joints
is clinically noteworthy because of its potential to cause compressive myelopathy and neurologic
dysfunction.
Atlantoaxial involvement of the cervical spine
RA rarely affects the
thoracic and lumbar spine.
occur commonly in px with RA, but they are generally not associated with significant symptoms. or functional impairment
Radiographic abnormalities of the temporomandibular joint
most frequently observed extraarticular manifestations
- Subcutaneous nodules
- secondary Siogren’s syndrome
- interstitial lung disease (ILD)
- pulmonary nodules
- anemia
CONSTITUTIONAL Ssx of RA
- weight loss
- fever
- Fatigue
- Malaise
- depression, and in the most severe, cachexia
- reported to occur in 30-40% of patients
- When palpated, the nodules are generally firm; nontender; and adherent to periosteum, tendons, or bursae
Subcutaneous nodules
Defined by the presence of either:
- keratoconjunctivitis sicca (dry eyes)
- xerostomia (dry mouth) in association with another connective tissue disease, such as RA.
secondary Sjdgren’s syndrome
the most common pulmonary manifestation of RA, may produce pleuritic
chest pain and dyspnea, as well as a pleural friction rub and effusion
Pleuritis
Pleural effusions tend to be exudative with increased numbers of
monocytes and neutrophils.
- may also occur in px with RA and is heralded by symptoms of dry cough and progressive shortness of breath
- can be associated with cigarette smoking and is generally found in patients with higher disease activity
ILD
Diagnosis of ILD is readily made by ___which shows infiltrative opacification in the periphery of both lungs
high resolution chest computed tomography (CT) scan
are the main histological and radiologic patterns of ILD.
Usual interstitial pneumonia (UIP) and non-specific interstitial pneumonia (NSIP)
causes progressive scarring of the lungs that produces on chest CT scan honeycomb changes in the periphery and lower portions of the lungs.
UIP
In contrast, the most common radiographic changes in ___ are relatively symmetric and bilateral ground glass opacities with associated fine reticulations, with volume loss and traction bronchiectasis
NSIP
Is defined by the clinical triad of neutropenia, splenomegaly, and nodular RA and is seen in <1% of patients, although its incidence appears to be declining in the face of more aggressive treatment of the joint disease.
Felty’s syndrome
- most common cause of death in patients with RA
- incidence of coronary artery disease and carotid atherosclerosis is higher in RA patients than in the general population
Cardiovascular Disease
more common in patients with RA than an age- and sex-matched population, with prevalence rates of 20-30%
Osteoporosis
Men and postmenopausal women w/ RA have lower mean serum testosterone, LH, and dehydroepiandrosterone (DHEA) levels than control population
Hypoandrogenism
RA occurs more commonly in
females
The alleles known to confer the greatest risk of RA are located within
major histocompatibility complex (MHC)
Most, but probably not all, of this risk is associated with allelic variation in the ___, which encodes the MHC II B- chain molecule.
HLA-DRB1 gene
non-MHC genes contributing to the risk of RA is the gene encoding
protein tyrosine phosphatase non-receptor 22 (PTPN22)
gene is another risk allele that encodes an enzyme involved in the conversion of arginine to citrulline and is postulated to play a role in the development of antibodies to citrullinated antigens
peptidyl arginine deiminase type IV (PADI4)
Has been associated with RA only in Asian populations
Polymorphism in PADI4
confers a relative risk for developing RA of 1.5-3.5
smoking
women who smoke cigarettes have a nearly 2.5 times greater risk of RA, a risk that persists even ___ after smoking cessation.
15 years
may play a role in the pathogenesis of RA
Periodontitis
Multiple studies provide evidence for a_ link between anti-CCP positive RA and _ cigarette smoking, periodontal disease, and the oral microbiome, specifically
Porphyromonas gingivalis
Classification Criteria for Rheumatoid Arthritis
JOINT INVOLVEMENT
- 1 large joint (shoulder, elbow, hip, knee, ankle)
involvement - 2-10 large joints
- 1-3 small joints (MCP PIP thumb IP MTP wrists)
- 4-10 small joints
- > 10 joints (at least 1 small joint)
- 0
- 1
- 2
- 3
- 5
Classification Criteria for Rheumatoid Arthritis
Serology
- Negative RF and negative ACPA
- Low-positive RF or low-positive anti-CCP
antibodies (<3 times ULN)
- High-positive RF or high-positive anti-CCP 3 antibodies (>3 times ULN)
- 0
- 2
- 3
Classification Criteria for Rheumatoid Arthritis
Acute Phase Reactants
- Normal CRP and normal ESR reactants
- Abnormal CRP or abnormal ESR
- 0
- 1
Classification Criteria for Rheumatoid Arthritis
Duration of Symptoms
- <6 weeks
- >/= 6 weeks
- 0
- 1
- Patients with systemic inflammatory diseases such as RA will often present with elevated nonspecific inflammatory markers such
ESR or CRP
is important in differentiating RA from other polyarticular diseases
Detection of serum RF and anti-CCP antibodies
has been found in 75-80% of patients with RA
Serum IgM RF
Showing the most value for predicting worse outcomes
anti-CCP antibodies
Synovial fluid white blood cell (WBC) counts can vary widely, but generally range between ___ WBC/uL compared to <2000 WBC/uL for a noninflammatory condition such as osteoarthritis
5000 and 50,000
is the most common imaging modality, but it is limited to visualization of the bony structures and inferences about the state of the articular cartilage based on the amount of joint space narrowing
Plain x-ray
offer the added value of detecting changes in the soft tissues such as synovitis, tenosynovitis, and effusions, as well as providing greater sensitivity for identifying bony abnormalities
MRI and ultrasound techniques
