RA (Darrow) - SRS Flashcards
Does a positive anti-ccp confirm dx of RA?
No
How long do symptoms need to go on before you can really think RA?
6 weeks
What lab tests must be done as baseline and followed prior to starting MTX?
LFT
What is the R in “median Trap”?
Rheumatoid Arthritis
What are some pretty typical components of the RA clinical picture?
Over 6 weeks
large number of joints
small joints affected
If you aspirate a septic joint, in general what is the most common organism you will find?
S. aureus
What infections might you expect in the septic joint of a gardener?
Sporotrichx schenkii
Nocardia
Blastomycosis
Pantoea (enterobacter) agglomerans
If exposed to spagnum moss you should think what organism?
Sporotrichosis
If exposed to rose bushes, think?
Nocardia
Exposed to decomposing wood?
Blastomycosis
What are the 6 main exams that you need to do on an RA patient?
- Eye
- Mouth
- Neck
- Lung
- Skin
- Abdominal
What might be found in an RA patient’s eye exam?
- Scleritis
- scleromalacia perforans
- Rheumatoid nodules
- Dry eyes
What might you see on oral inspection of a patient with RA?
- Xerostomia
- Dental caries
What might you find on neck exam/imaging of a patient with RA?
- A-A subluxation
- Erosion of the odontoid process
- C-Spine ankylosis
If an RA patient has a subluxed AA, what do they tend to have symptom wise from this?
C2 radiculitis and myelopathic symptoms, including extremity weakness, gait
and balance problems.
What are some lung findings you might see in an RA patient?
- Cough
- Dyspnea
- Crackles (d/t pulmonary fibrosis)
When listening to an RA patients lungs what should you have them do?
Cough, if the crackles clear you know it isn’t fibrosis. If they remain, then it points to pulmonary fibrosis of some sort.
What are some skin lesions you might see in an RA patient? 5
- Rheumatoid nodules
- pyoderma gangrenosum
- Sweet’s syndrome
- Circle purpura d/t small vessel vasculitis (early)
- Livedo Reticularis (much more common in SLE or polyarteritis nodosum)
What is Caplan’s syndrome?
Combination of pulmonary rheumatoid nodules and pneumoconiosis d/t silica, coal dust or asbestos
If an RA patient with an eroded odontoid process undergoes anesthesia, what may happen?
The relaxation can lead to “pithing” the patient and they can die.
What is the process that leads to pyoderma gangrenosum and Sweet’s syndrome?
IL - 8 signals for neutrophils, which produce cytokines and inflammatory mediators that lead to these conditions.
What is scleromalacia perforans?
The sclera perforates and the humor of the eye leaks out, leaving the eye flat.
What might you find in abdominal exam?
- Splenomegaly
What is Felty’s syndrome?
- Splenomegaly
- Anemia
- Neutropenia/Nodules
- Thrombocytopenia
- Arthritis
Santa’s Felty cap
What is shown here?
- Swan neck deformity
- Boutonniere deformity
What is shown here?
What are two conditions this is seen in?
AA subluxation
RA and DISH
If a patient has rheumatoid nodules, what does this tell you about the patients disease?
- Will be RF seropositive
- More likely to have anti-ccp (ACPA)
- Greater chance of vasculitis
Is there RF negative RA? What will probably be absent?
Yes
Probably no nodules
What is this?
Seen in?
Neutrophilic dermatosis/Sweet’s syndrome - Seen in RA
What is this finding?
Seen in?
Small vessel vasculitis – circular purpura
RA
What is shown here?
Pyoderma Gangrenosum
What percent of Felty’s syndrome patients have rheumatoid nodules?
~75%
What are the four classification criteria for RA diagnosis?
- Number and site of involved joints
- Serological abnormality
- Elevated acute phase response
- Symptom duration
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
- 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
According to the 2010 classification criteria for RA, how many points are needed for a dx of RA?
6/10
What is the hot new diagnostic tool for RA?
14-3-3n
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?
- Regulation of protein phosphorylation
- mitogen-activated protein kinase pathways
14-3-3η is useful in?
Diagnosing Early RA
Rheumatoid Factor is what?
Anti IgG in the form of either IgM or IgG
Which is a worse disease course, RF from IgM or IgG?
IgM
Another scoring method for RA is the multibiomarker disease activity score (MBDA).
What is a high score?
What would that indicate?
A high score, MBDA > 44, indicates rapid radiologic progression and response to TNFi therapy.
What are four rheumatic diseases where RF may be seen?
- Cryoglobulinemia*
- Sjogrens
- RA
- MCTD
What are some infections that can come with +RF?
One category is viruses, what virus in particular?
Parasites
Leprosy
SBE
Viruses (Hep C especially)
What are some lung diseases with RF positivity?
Silicosis
IPF
What is one organism that inhabits the oral cavity and tends to nudge people into RA?
How does it do this?
Porphyromonas gingivalis - pumps out cyclic citrullinated protein in excess quantity, leading to the body mounting an anti-CCP response, starting the RA course.
What are some other organisms besides Porphyromonas gingivalis that can lead to RA?
Prevotella
Lepotrichia
Proteus mirabilus
What HLA haplotype is associated with a predisposition for RA?
HLA-DRB (SE Allele carriers)
What imaging modalities may be useful in assessing RA?
X-ray
MRI
US
What is another abbreviation we should know for Anti-CCP?
ACPAs - apparently this one is more common in practice
What is shown here?
Disease?
Marginal erosions at the radial side of the PIPs with joint space narrowing
RA
What is shown in this x-ray?
Gout - note the more significant lateral extensions from the bone
What is shown here?
MRI in RA showing erosion
What is the obscured finding in this US from an RA patients hand?
An erosion
In early RA, what cells hyperplase?
What cells activate?
- Synovial cell hyperplasia
- endothelial cell activation
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?
- IL-1
- IL-6
- IL-8
- TGF-B
- FGF
- PDGF
Ultimately, inflammation and exuberant proliferation of the synovium (ie, pannus) leads to destruction of?
- cartliage
- bone
- tendons
- ligaments
- blood vessels
What are some other forms of arthritis that RA must be distinguished from? 5
- Osteoarthritis
- Gout
- Spondyloarthropathies
- Lyme arthritis
- FMF (famillial mediterranean fever)
What are some infections that can produce an RA like clinical picture? 2
Parvo B19
Hepatitis C
What are four collagen vascular diseases that can produce an RA type clinical picture?
- SLE
- Polymyalgia rheumatica
- Wegeners
- RF
What is used to gauge therapeutic strategy and prognosis in rheumatoid arthritis?
Disease activity score 28 (DAS28)
What are the components of the DAS28?
4
- # of tender joints
- # of swollen joints
- ESR
- Patient rating of global arthritis during last week: 0-100
What is yet another test that we can use to evaluate RA disease activity?
Vectra test ( 12 biomarkers)
The vectra test uses 12 biomarkers with emphasis on which 3?
- CRP
- IL-6
- SAA
What vectra scores fall into the low, moderate and high ranges?
Low: 1-29
Moderate: 30-44
High: 45-100
What are the components of triple therapy?
- MTX
- Sulfasalazine
- Hydroxychloroquine
What are the biologic DMARDS?
TNFi -
Abatacept – blocks T cell costimulation
Rituximab – depletes B cells
Tocilizumab - blocks IL6 receptor
Tofacitinib – inhibits Janus Kinase 3
What drugs are interfering with the RA process at each point indicated by a red box?
If a patient has an RA clinical picture that could be characterized as severe, what do we want to do to treat?
MTX and biological DMARDs
What are some complications of long term RA? 6
- MI
- Osteoporosis
- NSAID bleeds
- GI perforations
- Lymphoma
- GU malignancies
How long before an anti RA regimen consiting of MTX and Etanercept kicks in?
4 months minimum, but likely 6 - 12 months
