Reactive and rheumatoid arthritis Flashcards
What is arthritis
‘catch all’ term for joint disease/inflammation
There are different types
what are the different types of arthritis
infectious
inflammatory
degenerative
rheumatologic
etc
What is arthritis usually associated with
bony changes such as osteophytes or cartilage loss
What is reactive arthritis also known as
Reiter’s syndrome
what is Reactive arthritis
asymmetric ologoarthritis (2-4 joints) precipitated by infection
most often involved the LE joints and associated with extra-articular manifestations
what is the typical presentation of patient with reactive arthritis
M>F (9:1)
average: 20-40 yo
50-80% of patient are HLA-B27 positive
caucasian >
+FH of reactive arthritis increases risk
What is the pathophysiology of reactive arthritis
most commonly secondary to GI/GU infection - exact bacterial pathogenesis unclear
what are the common GI pathogens that can cause reactive arthritis
Shigella
Salmonella
Yersinia
Campylobacter
What are the common GU pathogens that can cause reactive arthritis
chlamydia tachomatis
ureaplasma urealyticum
what is the presentation of a patient with Reactive arthritis
Asymmetric oligoarthritis
predominantly affects the LE joints (Knees and ankle most common)
joint stiffness/decreased ROM
joint effusion
joint tenderness
What are some co-accuring signs of reactive arthritis
Enthesitisi (inflammation at tendon/ligament attachments)
Dactylitisi (sausage bigits)
Mucocutaneous lesions - painless oral ulcers, circinate balanitis, urethritis/cervicitis
What are the occular symptoms associated with reactive arthritis
conjunctivitis, anterior uvelitis, iritis, scleritis, episcleritis, keratitis (cornea)
What are the cardiac manifestations of reactive arthritis
aortitis, valvular involvement, heart block
What is the typical presentation for reactive arthritis
Cant see, cant pee, cant climb a tree, cant have sex with me
conjunctivitis, urethritis, arthritis, GU infection
How is reactive arthritis worked up?
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
What is the treatment of reactive arthritis
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
What is psoriatic arthritis?
inflammatory arthritis secondary to psoriasis
what is the typical population for psoriatic arthritis
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
What are the five different disease patterns for psoriatic arthritis
- symmetric polyarthritis
- asymmetric mono-or oligoarthritis
- monoarthritis of the DIP (often with nail pitting and onycholysis)
- axial arthritis - sacroiliitis and spinal involvement (strong association with HLA-B27)
- arthritis mutilans (severe, widespread and results in deformity)
what is the typical presentation of psoriatic arthritis
primarily involve the hands and feet but also knees and hips
dactylitis (sausage digits)
Nail pitting
onycholysis
enthesitis
ocular inflammation
How is psoriatic arthritis worked up?
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
What are the supportive diagnostics for psoriatic arthritis
synovial fluid - inflammatory (elevated WBC, PMN% and negative gram stain and culture)
Elevated ESR/CRP
RF negative but may have false positive
What is the first line treatment for psoriatic arthritis
Biologic DMARDs
- TNF-alpha inhibitors/monoclonal antibodies (entanercept, infliximab, adalimumab)
What are other treatment options for psoriatic arthritis
NSAIDS (high dose, consistent administration)
Non-biologic DMARDs (methotrexate, sulfasalazine, hydrochloroqine)
What medications are not helpful for the treatment of PsA
Corticosteroids are not effective in PsA and may precipitate pustular psoriasis during tapers
What is Rheumatoid arthritis
inflammatory symmetric polyarthritis - chronic disease
inflammation of synovial membrane - synovitis ad proliferation which leads to progressive joint damage and deformity
what is the average onset of rheumatoid arthritis in women vs men
women: 30-50
Men: 50-70
what are risk for the development of developing RA
strong genetic association - HLA-DR most strongly associated
smoking and periodontitis increase risk
F>M
What are the joint involvement/ presentation of RA?
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)
What are the articular symtpoms associated with RA
hands and wrists involved in almost all patients
late stage associated with gross deformities, and loss of function
what are the extra-articular symptoms?
most seropositive for RF or ACPA
Rheumatoid nodules (20%)
Dryness of eyes, mouth, mucous membranes
scleritis, episcleritis, keratitis
interstitial lung disease, pericarditis, vasculitis
What are the preferred diagnostic test for RA?
x-rays are first line imagine
often normal early on (first 6 months or so)
supportive findings: osteopenia, Juxta-articular erosions, symmetric joint degenerations
what labratory findings are used for RA
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
What is ACPA
anti-CCP (anti-cyclic citrullinated peptide antiboties)
What are the differential diagnosis for RA?
OA
Gout
Septic arthritis
Vital syndromes
PsA, active arthritis
gout/pseudogout
SLE
plymyalgia rheumatica
paraneoplastic syndromes
scarcoidosis
lyme disease
what is the mainstay treatment of RA
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
What are the other treatment options for RA
non-biologics MTX (first line)
Sulfasalazine or Hydroxychloroquine (second line)
other options: leflunomide, tofacitinib, minocycline
What is the prognosis for RA
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
what are the subtypes of juvenile idiopathic arthritis
oligoarticular
seronegative polyarticular
seropositive polyarticular
systemic
psoriatic
enthesis-related
which type of juvenile idiopathic arthritis is most common
most common subtype
four or less joints affected
F>M kids 1-7yo
asymmetric arthritis
need regular eye exams
What are important factors of seropositive polyarticular JIA
5 or more joint affected
RF positive
teenage girls - of color more susceptible
symmetric arthritis
what are important factors of seronegative polyarticular JIA
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)
what are important factors of systemic JIA
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
what are important factors of psoriatic JIA
looks like adult PsA - one or more joints involved
psoriatic rash OR + FH of psoriasis
What are important factors of Enthesitis-Related JIA
pain and stiffness at tendon/ligament attachement sites
LE
MALES 8-12
elevated ESR/CRP associated with HLA-B27
What is the workup for any JIA
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
what is the tx for JIA
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
