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MSK II - Exam 2 > RA (Darrow) - SRS > Flashcards

RA (Darrow) - SRS Flashcards

1
Q

Does a positive anti-ccp confirm dx of RA?

A

No

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2
Q

How long do symptoms need to go on before you can really think RA?

A

6 weeks

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3
Q

What lab tests must be done as baseline and followed prior to starting MTX?

A

LFT

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4
Q

What is the R in “median Trap”?

A

Rheumatoid Arthritis

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5
Q

What are some pretty typical components of the RA clinical picture?

A

Over 6 weeks

large number of joints

small joints affected

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6
Q

If you aspirate a septic joint, in general what is the most common organism you will find?

A

S. aureus

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7
Q

What infections might you expect in the septic joint of a gardener?

A

Sporotrichx schenkii

Nocardia

Blastomycosis

Pantoea (enterobacter) agglomerans

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8
Q

If exposed to spagnum moss you should think what organism?

A

Sporotrichosis

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9
Q

If exposed to rose bushes, think?

A

Nocardia

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10
Q

Exposed to decomposing wood?

A

Blastomycosis

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11
Q

What are the 6 main exams that you need to do on an RA patient?

A
  1. Eye
  2. Mouth
  3. Neck
  4. Lung
  5. Skin
  6. Abdominal
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12
Q

What might be found in an RA patient’s eye exam?

A
  1. Scleritis
  2. scleromalacia perforans
  3. Rheumatoid nodules
  4. Dry eyes
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13
Q

What might you see on oral inspection of a patient with RA?

A
  1. Xerostomia
  2. Dental caries
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14
Q

What might you find on neck exam/imaging of a patient with RA?

A
  1. A-A subluxation
  2. Erosion of the odontoid process
  3. C-Spine ankylosis
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15
Q

If an RA patient has a subluxed AA, what do they tend to have symptom wise from this?

A

C2 radiculitis and myelopathic symptoms, including extremity weakness, gait

and balance problems.

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16
Q

What are some lung findings you might see in an RA patient?

A
  1. Cough
  2. Dyspnea
  3. Crackles (d/t pulmonary fibrosis)
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17
Q

When listening to an RA patients lungs what should you have them do?

A

Cough, if the crackles clear you know it isn’t fibrosis. If they remain, then it points to pulmonary fibrosis of some sort.

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18
Q

What are some skin lesions you might see in an RA patient? 5

A
  1. Rheumatoid nodules
  2. pyoderma gangrenosum
  3. Sweet’s syndrome
  4. Circle purpura d/t small vessel vasculitis (early)
  5. Livedo Reticularis (much more common in SLE or polyarteritis nodosum)
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19
Q

What is Caplan’s syndrome?

A

Combination of pulmonary rheumatoid nodules and pneumoconiosis d/t silica, coal dust or asbestos

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20
Q

If an RA patient with an eroded odontoid process undergoes anesthesia, what may happen?

A

The relaxation can lead to “pithing” the patient and they can die.

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21
Q

What is the process that leads to pyoderma gangrenosum and Sweet’s syndrome?

A

IL - 8 signals for neutrophils, which produce cytokines and inflammatory mediators that lead to these conditions.

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22
Q

What is scleromalacia perforans?

A

The sclera perforates and the humor of the eye leaks out, leaving the eye flat.

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23
Q

What might you find in abdominal exam?

A
  1. Splenomegaly
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24
Q

What is Felty’s syndrome?

A
  1. Splenomegaly
  2. Anemia
  3. Neutropenia/Nodules
  4. Thrombocytopenia
  5. Arthritis

Santa’s Felty cap

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25
Q

What is shown here?

A
  1. Swan neck deformity
  2. Boutonniere deformity
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26
Q

What is shown here?

What are two conditions this is seen in?

A

AA subluxation

RA and DISH

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27
Q

If a patient has rheumatoid nodules, what does this tell you about the patients disease?

A
  1. Will be RF seropositive
  2. More likely to have anti-ccp (ACPA)
  3. Greater chance of vasculitis
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28
Q

Is there RF negative RA? What will probably be absent?

A

Yes

Probably no nodules

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29
Q

What is this?

Seen in?

A

Neutrophilic dermatosis/Sweet’s syndrome - Seen in RA

30
Q

What is this finding?

Seen in?

A

Small vessel vasculitis – circular purpura

RA

31
Q

What is shown here?

A

Pyoderma Gangrenosum

32
Q

What percent of Felty’s syndrome patients have rheumatoid nodules?

A

~75%

33
Q

What are the four classification criteria for RA diagnosis?

A
  1. Number and site of involved joints
  2. Serological abnormality
  3. Elevated acute phase response
  4. Symptom duration
34
Q

The number and site of involved joints can pump the RA score from 1-5 points. What does it take to get…

  • 1 point
  • 2 points
  • 3 points
  • 5 points
A
  • 1 point: 2-10 large joints
  • 2 points: 1-3 small joints
  • 3 points: 4-10 small joints
  • 5 points: Over 10 joints with at least one small joint
35
Q

According to the 2010 classification criteria for RA, how many points are needed for a dx of RA?

A

6/10

36
Q

What is the hot new diagnostic tool for RA?

A

14-3-3n

37
Q

14-3-3η is a member of the 14-3-3 proteins, a group of highly conserved proteins composed of several isoforms that are involved in?

A
  1. Regulation of protein phosphorylation
  2. mitogen-activated protein kinase pathways
38
Q

14-3-3η is useful in?

A

Diagnosing Early RA

39
Q

Rheumatoid Factor is what?

A

Anti IgG in the form of either IgM or IgG

40
Q

Which is a worse disease course, RF from IgM or IgG?

A

IgM

41
Q

Another scoring method for RA is the multibiomarker disease activity score (MBDA).

What is a high score?

What would that indicate?

A

A high score, MBDA > 44, indicates rapid radiologic progression and response to TNFi therapy.

42
Q

What are four rheumatic diseases where RF may be seen?

A
  1. Cryoglobulinemia*
  2. Sjogrens
  3. RA
  4. MCTD
43
Q

What are some infections that can come with +RF?

One category is viruses, what virus in particular?

A

Parasites

Leprosy

SBE

Viruses (Hep C especially)

44
Q

What are some lung diseases with RF positivity?

A

Silicosis

IPF

45
Q

What is one organism that inhabits the oral cavity and tends to nudge people into RA?

How does it do this?

A

Porphyromonas gingivalis - pumps out cyclic citrullinated protein in excess quantity, leading to the body mounting an anti-CCP response, starting the RA course.

46
Q

What are some other organisms besides Porphyromonas gingivalis that can lead to RA?

A

Prevotella

Lepotrichia

Proteus mirabilus

47
Q

What HLA haplotype is associated with a predisposition for RA?

A

HLA-DRB (SE Allele carriers)

48
Q

What imaging modalities may be useful in assessing RA?

A

X-ray

MRI

US

49
Q

What is another abbreviation we should know for Anti-CCP?

A

ACPAs - apparently this one is more common in practice

50
Q

What is shown here?

Disease?

A

Marginal erosions at the radial side of the PIPs with joint space narrowing

RA

51
Q

What is shown in this x-ray?

A

Gout - note the more significant lateral extensions from the bone

52
Q

What is shown here?

A

MRI in RA showing erosion

53
Q

What is the obscured finding in this US from an RA patients hand?

A

An erosion

54
Q

In early RA, what cells hyperplase?

What cells activate?

A
  1. Synovial cell hyperplasia
  2. endothelial cell activation
55
Q

CD4 T cells, mononuclear phagocytes, fibroblasts, osteoclasts, and neutrophils, and B cells (RF) play major roles. Cytokines, chemokines, and other inflammatory mediators are active, and include?

A
  1. IL-1
  2. IL-6
  3. IL-8
  4. TGF-B
  5. FGF
  6. PDGF
56
Q

Ultimately, inflammation and exuberant proliferation of the synovium (ie, pannus) leads to destruction of?

A
  1. cartliage
  2. bone
  3. tendons
  4. ligaments
  5. blood vessels
57
Q

What are some other forms of arthritis that RA must be distinguished from? 5

A
  1. Osteoarthritis
  2. Gout
  3. Spondyloarthropathies
  4. Lyme arthritis
  5. FMF (famillial mediterranean fever)
58
Q

What are some infections that can produce an RA like clinical picture? 2

A

Parvo B19

Hepatitis C

59
Q

What are four collagen vascular diseases that can produce an RA type clinical picture?

A
  1. SLE
  2. Polymyalgia rheumatica
  3. Wegeners
  4. RF
60
Q

What is used to gauge therapeutic strategy and prognosis in rheumatoid arthritis?

A

Disease activity score 28 (DAS28)

61
Q

What are the components of the DAS28?

4

A
  1. # of tender joints
  2. # of swollen joints
  3. ESR
  4. Patient rating of global arthritis during last week: 0-100
62
Q

What is yet another test that we can use to evaluate RA disease activity?

A

Vectra test ( 12 biomarkers)

63
Q

The vectra test uses 12 biomarkers with emphasis on which 3?

A
  1. CRP
  2. IL-6
  3. SAA
64
Q

What vectra scores fall into the low, moderate and high ranges?

A

Low: 1-29

Moderate: 30-44

High: 45-100

65
Q

What are the components of triple therapy?

A
  1. MTX
  2. Sulfasalazine
  3. Hydroxychloroquine
66
Q

What are the biologic DMARDS?

A

TNFi -

Abatacept – blocks T cell costimulation

Rituximab – depletes B cells

Tocilizumab - blocks IL6 receptor

Tofacitinib – inhibits Janus Kinase 3

67
Q

What drugs are interfering with the RA process at each point indicated by a red box?

A
68
Q

If a patient has an RA clinical picture that could be characterized as severe, what do we want to do to treat?

A

MTX and biological DMARDs

69
Q

What are some complications of long term RA? 6

A
  1. MI
  2. Osteoporosis
  3. NSAID bleeds
  4. GI perforations
  5. Lymphoma
  6. GU malignancies
70
Q

How long before an anti RA regimen consiting of MTX and Etanercept kicks in?

A

4 months minimum, but likely 6 - 12 months

71
Q
A

MSK II - Exam 2 (7 decks)

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