RA

Question 1

What is RA

Answer 1

Chronic inflammatory joint condition of the synovium

Question 2

Pathology of RA

Answer 2

The synovial membrane becomes hyperaemic and congested
The cells of the synovium proliferate and there is villus hypertrophy
The SM is infiltrated by lymphocytes and macrophages
There is vascular pannus at the cartilage synovial junction
Inc vol and cellular it’s if the synovial fluid
Atrophy of supporting muscles

Question 3

What is pannus

Answer 3

Any abnormal tissue that contains BV and cover normal body structure
MMP break down joint tissue and degrade cartilage
Pannus inc osteoclasts - destroy and damage the Bone

Question 4

Clinical features of RA

Answer 4

Symmetrical deforming polyarthritis affects the synovial lines of joints, bursa and \tendons
There are also extra articular features therefore the presentation can be variable
Can be gradual or acute or subacute
Palindromic - come and go
Mono articular or poly

Question 5

Exam findings for those with RA

Answer 5

MCP subluxation- ulnar deviation
Swan neck deformity - PIP tendon slippage at PIP
Boutonnières - tendon subluxation opposite direction
Z thumb - to PIP
Nodules - elbows, and over joints

Question 6

Which joint type is affected by

RA

Answer 6

Only synovial joint can be affected by RA as this is what is attacked leading to joint destructions and the symptoms patients get

Question 7

Immunopathology of RA

Answer 7

Aggregate of T cells, macrophages, plasma cells in the synovial membrane
Synovial fluid contains mainly neutrophils which release pr inflammatory cytokines - TNF alpha, IL1 and IL6
The interplay between the immune cells and cytokines cytokines enrages inflammation and joint destruction

Question 8

Ix RA

Answer 8

Anaemia do chronic disease 
Platelets inc due to inflamm
WCC inc inflam 
ESR andCRP inc
Rh F +ve 80%
AntiCCP ab they are to the fc portion of IgG
X-ray - soft tissue swelling 
Later - erosions synovium bone junction

Question 9

Which joint is typically spared

Answer 9

DiP

Question 10

What is bad lifestyle choice for RA

Answer 10

Smoking exacerbate it

Question 11

HLA associated with RA

Answer 11

HLADR4

HLADR1

Question 12

WHat are the cutaneous extra articular features in RA

Answer 12

Subcutaneous nodules
More common in RhF+ve
Rare if -ve
Results from small vessels vasculitis with fibrinois necrosis forming centre of the nodules
Hard rubbery mobile/stuck
Nailfold infarct
- small vessel vasculitis - splinter haemorrhages
Leg ulcers- mixed art/venous + vasculitis component

Question 13

Pulmonary extraarticular features

Answer 13

Pleural thickening
Pleural effusion - transudate low glucose
Pulmnodules - usually asymptomatic usuallly accompanies nodule elsewhere such as cutaneous
These plum nods are peripheral, cavitating and can cause effusion or bronchopleural fistula
Biopsy often done to rule out cancer
Fibrosis alveolitis - more common in men inflammation that leads to fibrosis
May need aggressive immunosuppression
Can be breathless - fine basal late inspiratory crackles
Restrictive defect
HRCT= honeycombing
Occasionally related to methotrexate use
Can have opportunistic infection = pneumosistis suspect in immunocompromised
Bronchilitis obliterans
Plum arteries

Question 14

Cardiac extra articular features

Answer 14

Pericarditis - usually asymptomatic
CAD - IHD inc - due to endothelial dysfunction due to systemic inflammatory response
Or more rarely coronary arthritis

Question 15

Neurological extra articular features

Answer 15

Peripheral neuropathy due to nerve entrapment in affected joints
Monomeuritis
Mononeuritis multiplex- vessels are affected hat supply to nerves causing a neuropathy
Myelopathy due to cervical spine instability
Can subluxation and compress the cervical spinal cord - Atlanto-axial joint - LMN at the site of the lesion and UMN signs below it
Careful in RA anaesthetic neck in anaesthesia

Question 16

What is felty’s syndrome

Answer 16

RA+splenomegaly +leukopenia

Question 17

Ocular extra-articular features

Answer 17

2ndary Sjorgens - Schumer tear test- dryeye, xerostomia dry tongue
Episcleritis/scleritis -can progress to scleromalacia performance
Drug - steroids - cataract, chloroquine - retinopathy

Question 18

Renal extra articular features

Answer 18

RA - membranous glomerulonephritis, and vasculitis, amyloid
Drug -
NSAIDs, interstitial nephritis

Question 19

Diff diag for ra

Answer 19

Post viral - parvovirus, rubella

Reactive arthritis, SLE, polyarticlar gout, polyarthrits OA

Question 20

Classification criteria of RA

Answer 20

American college of rheumatologist 
4 domains
A - joint involvement
Large 1 = 0
Large 2-10 =1
Small 1-3 =2
Small 4-10 = 3
>10 joint with at least 1 small = 5
B - serology 
-ve RhF -ve anti-CCP = 0
Low+ve RhF & low +ve anti-CCP = 2
High +ve RhF & high +ve anti-CCP = 3
C - acute phase reaction
Norma CRP &ESR = 0
Abnormal CRP & ESR = 1 
D- duration 
<6 weeks =0
>6 weeks =1

Question 21

Mx RA

Answer 21

Con - weightloss, exercise, physio, hydrotherapy, OT, education
MED - drugs - analgesia, NSAIDS, DMARDS - methotrexate, sulphasalazine, leflunamide, biological and steroids
Surg - replacement fusion of joints

Question 22

Types of biological therapy

Answer 22

Cytokine inhibition

Anti-B cell therapy

Question 23

Types of cytokine inhibition

Answer 23

Anti -TNF
- infliximab, etanercept, adalinumab
IL1 and IL6
-tocilizumab

Question 24

B cell biologics

Answer 24

Rituximab

B cell depletion

Question 25

T cell biologics

Answer 25

Inhibitors of T cell costimulation

Abaterecept

Question 26

What is t mx steps

Answer 26

1st line DMARD
2nd TNF alpha
TNF alpha and DMARDS
3rd line B cell, T cell, IL6