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Yr 3 MSK > RA > Flashcards

RA Flashcards

1
Q

definition of RA

A

Chronic inflammatory systemic disease characterized by symmetrical deforming polyarthritis and extra-articular manifestations.

it increases the risk of CVS by 2-3fold

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2
Q

aetiology of RA

A

autoimmune disease of unknown cause

associated with other autoimmune phenomenon - Raynaud’s. Sjogren’s

HLA DR-1 and DR-4 haplotypes predispose to RA - suseptable alleles share sequence that bind to arthritogenic peptides to CD4 T cells -> adaptive immune response

PAD enzymes deiminate arginine -> citrulline.

  • polymorphisms of PAD2 and 4 = increased deimination = predispose to RA
  • Ab to citrullinated proteins associated withRA (anti-cyclic citrulinated peptides - anti-CCP Ab)
  • suggest B cell involvement

rheumatoid factor - IgM Ab against Fc of IgG = loss of tolerance to IgG (B cell involvement)

T and B cell react with synoviocytes – viscious cycle of reciprocal activation between macrophage and synoviocytes = osteoclast resorb bone

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3
Q

epidemiology of RA

A

common

1% prevalence in pop, higher in smokers (increases citrullination in lungs)

more in females

30-50yrs

HLA DR4/DR1 linked - associated with increased severity

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4
Q

sx of RA

A

gradual (occasionally rapid) onset

symmetrical polyarticular joint pain, swelling, morning stiffness, impaired function - of the small joints of hands and feet, worse in morning

this can fluctate and larger joints can become involved

peripheral joints symmetrically - occasionally monoarticular involvement eg knee

fatigue

fever

weight loss

FHx of autoimmune/RA

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5
Q

signs of RA

A

polyarticular arthritis - most common sites in hands- small joints

early and late signs

joint swelling and effusions

joint tenderness, synovitis

painful/restricted movement

rheumatoid nodules - Firm subcutaneous nodules, deposition of inflammatory cells (e.g. on elbows, palms, over extensor tendons, lungs, cardiac, CNS, lymphadenopathy, vasculitis).

signs of complications

extra-articular manifestations effect 40%

splenomegaly

osteoporosis

amyloidosis

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6
Q

early arthritic signs of RA

A

inflammation, no joint damage

spindling of fingers

swelling at MCP, PIP, wrist or MTP joints - often symmetrical

warm, tender joints

reduction in range of movements

look for tenosynovitis or bursitis

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7
Q

late arthritic signs of RA

A

joint damage, deformity

symettrical deforming arthropathy

Ulnar deviation of fingers as a result of subluxation (partial dislocation) at MCP joints.

radial deviation of the wrist

volar subluxation at wrist - ulnar styloid points out = damage extensor tendons = finger drop

swan neck deformity - MCP and DIP fixed flexion, PIP extension

Boutonniere deformity (MCP and DIP joint extension, PIP flexion)

Z derformity of thumb

trigger finger (unable to straighten finger, tendon sheath nodule palpable) tendon rupture

wasting of small muscles of the hand, palmar erythema

hand extensor tendons may rupture

foot changes are similar

larger joints can be involved

atlanto-axial joint subluxation may threaten the spinal cord - rare - synovitis destroy the transverse ligament = dens unstable and moves back into spinal cord

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8
Q

signs of vasculitis (skin) as a complication of RA

A

Nail-fold infarcts,

digital gangrene,

ulcers,

pyoderma gangrenosum,

purpuric rash.

bleeding of small bv due to inflammation

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9
Q

lung complications of RA

A

Pleural effusion,

interstitial fibrosis,

rheumatoid nodules in parenchyma,

obliterative bronchioloitis.

organising pneumonia

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10
Q

heart complications of RA

A

Pericarditis,

pericardial rub,

myocarditis,

conduction abnormalities,

valvular regurgitation.

IHD

pericardial effusion

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11
Q

haematological complications of RA

A

anaemia of chronic disease

megaloblastic anaemia - high demand for folic acid

aplastic anaemia - from drugs

haemolytic anaemia - in Felty’s syndrome

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12
Q

neuromuscular complications of RA

A

mononeuritis multiplex

peripheral neuropathy

carpal tunnel syndrome

atlantoaxial subluxation

spinal cord compression

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13
Q

renal complications of RA

A

analgesic nephropathy

amyloidosis

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14
Q

eyes complications of RA

A

scleritis

episcleritis

keratitis - involves the cornea, corneal melt

scleromalacia

scleromalacia perforans

keratoconjunctivitis sicca

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15
Q

Ix for RA

A

bloods

acutely - joint aspiration to exclude septic arthritis

joint XR

MRI and US can identify synovitis more accurately and have a greater sensitivity in detecting bone erosions than XR - look for soft tissue

  • hope that XR is normal*
  • US - black is the fluid in the joint, a lot of vascularisation*
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16
Q

bloods for RA

A

low Hb - anaemia of chronic disease

high platelets

high ESR and CRP

rheumatoid factor (monoclonal IgM against Fc portion of IgG, present in 70% of patients and 5% normal population, associated with subcutaenous nodules and extra-articular manifestations) - . High titres associated with severe disease and erosions

antinuclear Ab (30%) - might predict disease progression

anti-cyclic citrullinated peptide (CCP) Ab

RF

17
Q

XR of RA

A

soft tissue swelling

angular deformity - subluxation

carpal destruction

periarticular erosions

osteoporosis/osteopenia

juxta-articular osteopeni

reduced joint space

18
Q
A

RA

19
Q

less common presentations of RA

A

sudden onset, widespread arthritis

recurring mono/polyarthritis of various joints (palindromic RA)

persistant monoarthritis (knee, shoulder, hip)

systemic illness with extra-articular sx - fatigue, fever, weight loss, pericarditis, pleurisy - but initially few joint problems (more common in females)

polymyalgic onset - vague limb girdle aches

recurrent soft tissue problems - frozen shoulder, carpal tunnel syndrome, de Quervain’s tenosynovitis

20
Q

palindromic RA

A

arthritis lasting hours or days runs to and fro, visiting and revisiting three or more sites, typically knees, wrists, and MCP joints.

It may presage RA, SLE, Whipple’s, or Behçet’s disease.

Remissions are (initially) complete, leaving no radiological mark.

21
Q

Felty’s syndrome

A

RA, splenomegaly and neutropenia

22
Q

diagnostic criteria for RA

A
23
Q

pathophysiology of RA

A

synovial inflammation

Producing more synovial fluid

= destruction of cartilage and bone

24
Q

acute management of rheumatoid arthritis

A
  1. mild - DMARD (hydroxychloroquine or sulfasalazine) + steroid + NSAID
  2. moderate - DMARD + consider biologic (eg TNF-a inhibitor eg enteracept / infliximab) + steroid + NSAID
25
Q

acute mx for rheumatoid arthritis if pregnant/considering pregnancy

A

steroid
if cant have steroids: sulfasalazine/hydroxychloroquine - need FBC before start, and every 8wks

26
Q

chronic mx of rheumatoid

A
  1. methotrexate + DMARD + steroid + NSAID
  2. triple DMARD (methotrexate +sulfasalazine + hydroxychloroquine) + steroid + NSAID
27
Q

monitoring for rheumatoid arthritis

A

Hepatitis B and C status, purified protein derivative (PPD), full blood count (FBC), and liver function tests (LFTs) need to be checked before starting disease-modifying antirheumatic drugs (DMARDs)
monitor FBC and LFT every 4-8wks
monitor disease using DAS score

28
Q

complications of rheumatoid arthritis

A
  • work disability
  • joint replacement
  • coronary artery disease
  • ILD
  • felty syndrome
  • carpal tunnel
  • methotrexate - liver and lung toxicity
  • TNF-a inhibitor -> malignancy and infections
  • reduced LE - mainly from coronary artery disease
29
Q

what is felty syndrome

A

presence of RA, splenomegaly, and low WCC

Yr 3 MSK (15 decks)

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