RA Flashcards
(42 cards)
How does inflammatory arthritis present?
Inflammatory arthritis (IA) may present fairly acutely usually within weeks or a few months.
It is typically worse in the morning and associated with > 30 minutes of morning stiffness. It improves with exercise/ as the day goes on.
What are the differentials for IA?
Connective tissue disease Vasculitis RA Ankylosing spondylitis Psoriatic arthritis Reactive arthritis IBD arthritis
When is IA more likely to be due to vasculitis or CTD?
In vasculitis/ CTD expect systemic features (weight loss, anorexia, fever, sweats, lethargy) and multisystem involvement.
When is RA more likely to be the cause of the PC?
The presence of a family history makes RA more likely as it has a strong genetic component.
The patient is at an age when this frequently presents. It, typically affects the small joints of hands, feet and wrists in a symmetrical distribution as in this case.
Dry eyes suggests Sjogren’s syndrome which is commonly associated with rheumatoid arthritis.
How does psoriatic arthritis present?
Psoriatic arthritis can take many forms e.g. polyarthritis, oligoarthritis, but is usually asymmetrical.
It may be associated with other features such as dactylitis and tendonitis.
What is arthritis mutilans?
The term “arthritis mutilans” refers to an extremely severe form of psoriatic arthritis characterised by resorption of bones and the consequent collapse of soft tissue.
When this affects the hands, it can cause a phenomenon sometimes referred to as “telescoping fingers.” Similar changes can occur in the feet. It is not seen in RA.
How does reactive arthritis present?
It usually affects younger patients and presents with an asymmetric oligoarthritis shortly after infection with an enteropathic or genitourinary organism.
How does OA present?
Non- inflammatory/ Osteoarthritis (OA) is usually insidious in onset, sometimes over years.
It involves < 30 minutes of morning stiffness and is typically worsened by activity and worse towards the end of the day.
How does septic arthritis present?
With an acute history- onset over hours/days - infection should be considered. This is particularly the case for monoarthritis and oligoarthritis.
Look for underlying risk factors such as diabetes and immunosuppression.
Also, there are likely to be systemic features such as sweats and fevers and the patient is likely to feel generally unwell.
How does gout present?
Gout/ Pseudogout should be considered with an acute history. Risk factors for gout include a family history of gout, and purine consumption.
Pseudogout is more likely in elderly patients with underlying osteoarthritis.
Acute attacks of gout often affects the first metatarsophalangeal joint
Which questions should you ask to determine if pain and swelling of the hands is due to IA?
When did your symptoms start?
Did they start suddenly or build up gradually?
Do your symptoms typically vary throughout the day?
When are they at their worst?
What happens if you exercise?
How do you feel first thing in the morning?
Do your joints ever feel stiff? If so for how long?
What does boggy swelling indicate?
“Boggy” swelling feels similar to when you squash a grape and is suggestive of synovitis which occurs in IA. In OA swelling is bony in nature.
What is RA?
Rheumatoid arthritis (RA) is a common chronic inflammatory autoimmune disease characterised by an inflammation of the synovial joints leading to joint and periarticular tissue destruction, as well as a wide variety of extra-articular features.
Why is it important to diagnose RA in its early stages?
Suppression of inflammation in the early stages of the disease can result in substantial improvements in long-term outcomes.
There is evidence that the first 12-week period of the disease is immunologically distinct and represents a unique opportunity to influence the progress of the disease.
Once mechanical damage has occurred, pain and joint deformity often require aids and appliances and, eventually, surgery.
What is the pathophysiology of RA?
In RA, the synovium becomes inflamed and thickened and proliferative synovitis (pannus) can be seen. Angiogenesis occurs enabling movement of leucocytes from the blood to the synovial tissues.
The intima contains greatly increased numbers of inflammatory cells including macrophages, fibroblasts, T-cells, B-cells and plasma cells. The synovial fluid becomes a fibrinous inflammatory exudate, containing many neutrophils.
Local release of matrix-degrading enzymes and mediators of inflammation may damage the adjacent cartilage and result in the formation of erosions.
What are the risk factors for RA?
RA results from an interaction between genetic susceptibility and environmental factors, including high birth weight, smoking, silica exposure, alcohol abstention, obesity, diabetes mellitus, rheumatoid factor, and anti-citrullinated protein (CCP) antibody.
Smoking is an important risk factor.
HLA DR4 and DR1 are associated, especially with severe disease.
What is the challenge for GPs with the presentation of RA?
The challenge for GPs is to recognise early symptoms and refer early. The presentation can be very variable. Constitutional symptoms (eg, profound fatigue, influenza-like symptoms, fever, sweats and weight loss) are common.
How does RA present?
Arthritis:
Usually starts as an insidious symmetrical polyarthritis, often with nonspecific systemic symptoms.
RA can affect any synovial joint but typically affects the small joints of the hands and the feet. It is usually bilateral and symmetrical in distribution.
More joints are affected with the progression of the disease.
Joint inflammation produces characteristic changes: heat and sometimes redness, swelling, pain, stiffness (especially in the early morning or after inactivity), progressive joint destruction and loss of joint function.
Pain, swelling, muscle wasting and damage to joints result in progressive deformity, disability and handicap.
Tendon sheaths have synovial linings and inflammation of these can result in tendon rupture.
What is palindromic rheumatism?
Palindromic rheumatism is a rare form of inflammatory arthritis.
Attacks of joint pain and swelling are similar to rheumatoid arthritis, but the joints return to normal between attacks.
Patients with palindromic rheumatism may later develop rheumatoid arthritis.
What are the signs of rheumatoid arthritis?
Shoulders, elbows and hips are less commonly affected.
Hand deformities, including ulnar deviation, swan neck and Boutonnière’s deformity of the fingers, Z deformities of thumbs and piano key deformity of the wrist.
The characteristic features of the hands in patients with RA are subluxation of the metacarpophalangeal joints, radial deviation of the wrist joint and ulnar deviation of the fingers.
Muscle wasting and tendon rupture.
Cervical complications (instability of the cervical spine).
What is swan-neck deformity?
Swan-neck deformity (proximal interphalangeal joint hyperextension with concurrent distal interphalangeal joint flexion) occurs in patients with RA, but may also follow trauma or be congenital.
What is boutonniere deformity?
Boutonnière deformity (flexion of the proximal interphalangeal joint accompanied by hyperextension of the distal interphalangeal joint) can result from tendon laceration, dislocation, fracture, osteoarthritis or RA.
What is the percentage of patients with RA with extra-articular features?
40%
What are the extra-articular features seen in RA?
Eyes: secondary Sjögren’s syndrome, scleritis and episcleritis.
Scleromalacia performans- occurs where there is rupture of the globe due to weaking of the scleral layer.
Skin: leg ulcers especially in Felty’s syndrome (association of rheumatoid factor positive rheumatoid arthritis, neutropenia and splenomegaly). Rashes, nail fold infarcts.
Rheumatoid nodules: these are common, and may occur in the eyes, may be subcutaneous, and may be in the lung, heart and occasionally the vocal cords.
Neurological: peripheral nerve entrapment, atlanto-axial subluxation, polyneuropathy, mononeuritis multiplex.
Respiratory system: pleural involvement, pulmonary nodules, pulmonary fibrosis, obliterative bronchiolitis, Caplan’s syndrome.
Cardiovascular system: cardiovascular disease, pericardial involvement, valvulitis and myocardial fibrosis, immune complex vasculitis.
Kidneys: rare, including analgesic nephropathy, amyloidosis.
Liver: mild hepatomegaly and abnormal transaminases are common.
Other: thyroid disorders, osteoporosis, depression, splenomegaly and susceptibility to infections.
