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Clin Med MSK: > Reactive and rheumatoid arthritis > Flashcards

Reactive and rheumatoid arthritis Flashcards

1
Q

What is arthritis

A

‘catch all’ term for joint disease/inflammation
There are different types

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2
Q

what are the different types of arthritis

A

infectious
inflammatory
degenerative
rheumatologic
etc

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3
Q

What is arthritis usually associated with

A

bony changes such as osteophytes or cartilage loss

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4
Q

What is reactive arthritis also known as

A

Reiter’s syndrome

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5
Q

what is Reactive arthritis

A

asymmetric ologoarthritis (2-4 joints) precipitated by infection

most often involved the LE joints and associated with extra-articular manifestations

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6
Q

what is the typical presentation of patient with reactive arthritis

A

M>F (9:1)
average: 20-40 yo
50-80% of patient are HLA-B27 positive
caucasian >
+FH of reactive arthritis increases risk

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7
Q

What is the pathophysiology of reactive arthritis

A

most commonly secondary to GI/GU infection - exact bacterial pathogenesis unclear

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8
Q

what are the common GI pathogens that can cause reactive arthritis

A

Shigella
Salmonella
Yersinia
Campylobacter

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9
Q

What are the common GU pathogens that can cause reactive arthritis

A

chlamydia tachomatis
ureaplasma urealyticum

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10
Q

what is the presentation of a patient with Reactive arthritis

A

Asymmetric oligoarthritis
predominantly affects the LE joints (Knees and ankle most common)

joint stiffness/decreased ROM
joint effusion
joint tenderness

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11
Q

What are some co-accuring signs of reactive arthritis

A

Enthesitisi (inflammation at tendon/ligament attachments)
Dactylitisi (sausage bigits)
Mucocutaneous lesions - painless oral ulcers, circinate balanitis, urethritis/cervicitis

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12
Q

What are the occular symptoms associated with reactive arthritis

A

conjunctivitis, anterior uvelitis, iritis, scleritis, episcleritis, keratitis (cornea)

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13
Q

What are the cardiac manifestations of reactive arthritis

A

aortitis, valvular involvement, heart block

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14
Q

What is the typical presentation for reactive arthritis

A

Cant see, cant pee, cant climb a tree, cant have sex with me

conjunctivitis, urethritis, arthritis, GU infection

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15
Q

How is reactive arthritis worked up?

A

clinical diagnosis - no specific lab test
supportive diagnostics:
synovial fluid - inflammatory, Elevated ESR/CRP, RF negative

ID causative agent: urine culture, stool testing, STI screen, blood cultures

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16
Q

What is the treatment of reactive arthritis

A

infections need to be properly treated - reactive arthritis will decrease with timely treatment of STI

mainstay: NSAIDS - high dose, continuous
Second line: intra-articular or systemic steroids
if persistant: sulfasalazine or MTX

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17
Q

What is psoriatic arthritis?

A

inflammatory arthritis secondary to psoriasis

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18
Q

what is the typical population for psoriatic arthritis

A

affects 5-20% of patients with psoriasis (M=F), average age 30-55
5x more common in those with severe skin symptoms vs mild
50% have positive HLA- B27

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19
Q

What are the five different disease patterns for psoriatic arthritis

A
  1. symmetric polyarthritis
  2. asymmetric mono-or oligoarthritis
  3. monoarthritis of the DIP (often with nail pitting and onycholysis)
  4. axial arthritis - sacroiliitis and spinal involvement (strong association with HLA-B27)
  5. arthritis mutilans (severe, widespread and results in deformity)
20
Q

what is the typical presentation of psoriatic arthritis

A

primarily involve the hands and feet but also knees and hips
dactylitis (sausage digits)
Nail pitting
onycholysis
enthesitis
ocular inflammation

21
Q

How is psoriatic arthritis worked up?

A

x-ray is the preferred imaging and is useful for differentiation between other arthritides

erosion of the articular surface and surrounding bone in the DIP and PIP
Arthritis mutlians - opera glass hands, telescoping

22
Q

What are the supportive diagnostics for psoriatic arthritis

A

synovial fluid - inflammatory (elevated WBC, PMN% and negative gram stain and culture)
Elevated ESR/CRP
RF negative but may have false positive

23
Q

What is the first line treatment for psoriatic arthritis

A

Biologic DMARDs
- TNF-alpha inhibitors/monoclonal antibodies (entanercept, infliximab, adalimumab)

24
Q

What are other treatment options for psoriatic arthritis

A

NSAIDS (high dose, consistent administration)
Non-biologic DMARDs (methotrexate, sulfasalazine, hydrochloroqine)

25
Q

What medications are not helpful for the treatment of PsA

A

Corticosteroids are not effective in PsA and may precipitate pustular psoriasis during tapers

26
Q

What is Rheumatoid arthritis

A

inflammatory symmetric polyarthritis - chronic disease
inflammation of synovial membrane - synovitis ad proliferation which leads to progressive joint damage and deformity

27
Q

what is the average onset of rheumatoid arthritis in women vs men

A

women: 30-50
Men: 50-70

28
Q

what are risk for the development of developing RA

A

strong genetic association - HLA-DR most strongly associated
smoking and periodontitis increase risk
F>M

29
Q

What are the joint involvement/ presentation of RA?

A

includes articular and extra-articular manifestations
articular symptoms - usually occur over weeks - months
small joints affected (PIP, MCP, MTP, TMJ) - SPARES THE DIP AND THORACIC LUMBAR SPINE
involves larger joints later (wrist, knees, elbows, ankles, hips, shoulders)

30
Q

What are the articular symtpoms associated with RA

A

hands and wrists involved in almost all patients
late stage associated with gross deformities, and loss of function

31
Q

what are the extra-articular symptoms?

A

most seropositive for RF or ACPA
Rheumatoid nodules (20%)
Dryness of eyes, mouth, mucous membranes
scleritis, episcleritis, keratitis
interstitial lung disease, pericarditis, vasculitis

32
Q

What are the preferred diagnostic test for RA?

A

x-rays are first line imagine
often normal early on (first 6 months or so)

supportive findings: osteopenia, Juxta-articular erosions, symmetric joint degenerations

33
Q

what labratory findings are used for RA

A

presence of Anti-CCP antibodies (anti-cyclic citrullinated peptide antibodies) - most sensitive and specific
+ RF or + ANA
most have elevated ERS/CRP
May also see CBC abnormalities (anemia, elevated platelet count during flare, normal or elevated WBC count)
synovial fluid inflammatory

34
Q

What is ACPA

A

anti-CCP (anti-cyclic citrullinated peptide antiboties)

35
Q

What are the differential diagnosis for RA?

A

OA
Gout
Septic arthritis
Vital syndromes
PsA, active arthritis
gout/pseudogout
SLE
plymyalgia rheumatica
paraneoplastic syndromes
scarcoidosis
lyme disease

36
Q

what is the mainstay treatment of RA

A

DMARDS (TNF inhibitors)
reduce inflammation and pain
joint preservation and eformity prevention - irreversible once present
should be started as early as possible

systemic corticosteroids often started first until DMARDs take effect

37
Q

What are the other treatment options for RA

A

non-biologics MTX (first line)
Sulfasalazine or Hydroxychloroquine (second line)
other options: leflunomide, tofacitinib, minocycline

38
Q

What is the prognosis for RA

A

it is associated with increased mortality risk
- 8 years earlier for Males and 10 years earlier for Females (associated with CVD)
RA also confer increased risk for osteoporosis, lymphoma and infections
50% or more RA patient have to stop worked after 5-10 years

39
Q

what are the subtypes of juvenile idiopathic arthritis

A

oligoarticular
seronegative polyarticular
seropositive polyarticular
systemic
psoriatic
enthesis-related

40
Q

which type of juvenile idiopathic arthritis is most common

A

most common subtype
four or less joints affected
F>M kids 1-7yo
asymmetric arthritis
need regular eye exams

41
Q

What are important factors of seropositive polyarticular JIA

A

5 or more joint affected
RF positive
teenage girls - of color more susceptible
symmetric arthritis

42
Q

what are important factors of seronegative polyarticular JIA

A

five or more joints
symmetric or asymmetric
younger children, peask in ages 1-3, and agan later in teens
F>M
Negative RF at onset but can transition to seropositive (+ RF)

43
Q

what are important factors of systemic JIA

A

variable number of joints
males = females peaks about 2yo
WITH FEVER AND SALMON COLORED RASH
Must rule out malignancy/infection
macrophage activation syndrome - potentially life threatening complication , very high serium ferritin

44
Q

what are important factors of psoriatic JIA

A

looks like adult PsA - one or more joints involved
psoriatic rash OR + FH of psoriasis

45
Q

What are important factors of Enthesitis-Related JIA

A

pain and stiffness at tendon/ligament attachement sites
LE
MALES 8-12
elevated ESR/CRP associated with HLA-B27

46
Q

What is the workup for any JIA

A

diagnosis of exlusion - no specific lab tests, need to rule out infection, malignancies and other rheumatologic diseases

CBC, ESR/CRP, LFTS and renal function tests,, ANA and RF, HLA-B27

Radiographs used to rule out other joint pathology but usually normal

47
Q

what is the tx for JIA

A

initiated early to control symptoms and prevent disability/deformity
1/2 need to continue treatment into adulthood

First line: NSAID and corticosteroids
If continued symtoms: start DMARDS - MTX
if seropositive: DMARDS to start

Clin Med MSK: (14 decks)

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