Rhematoid Arthritis Flashcards
Define rheumatoid arthritis?
A chronic autoimmune symmetrical small joint inflammatory polyarthritis (4 or more joints)
Describe the presenting features of RA?
Joints are red, swollen (cystic), painful, morning stiffness
Usually starts in the hands followed by the feet.
Symmetrical
Classically affects the MCP and PIP’s sparing the DIP’s.
Weight loss, myalgia
30-50Y old
How is RA diagnosed and how should it be investigated?
Clinical diagnosis as not a specific test 100% diagnostic
Basline
- FBC (anaemic), platelets (raised), ESR, LFTS, U+E
To exclude other diseases
- ANA, Serum uric acid, may need joint analysis
- Urinalysis
Diagnostic
- RF, Anti CCP
- X-ray the hands and feet
Whta does seropositive mean?
Refers to the presence of serological markers in the blood.
In RA’s case these are CCP or Rheumatoid factor
What proprtion of patients with RA are seropositive?
Roughly 75% at diagnosis likley goes up
Describe the following signs?
Swan neck deformity
Hyperextension at the PIP with flexion at the DIP
Describe the following signs?
Boutonniere deformity
Flexion at the PIP joint and hyperextension at the DIP.
Describe the following signs?
Anterior subluxation of the anterior metacarpal phalangeal joint
Ulnar deviation of the phalanges at the MCP joint
Nodes
What are the early and laye X-ray changes associated with RA?
Early
- Joint space narrowing
- Soft tissue swelling around joints (PIJ not DIJ)
- Juzta-articular osteopenia (bone looks thinner next to joint)
Late
- Bony erosions (look for loss of trabecular network)
- Subluxation
Describe the treatment of RA
Early treatment (within 3 months improves long term prognosis)
- Lifestyle: Smoking, exercise, CV mod
- DMARDS: methotrexate and hydroxyquinine (or sulfasalazine)
- IM/ intraarticular steroids until DMARDS work (2-3 months)
- MDT approach
Further down the line
- Anti TNFs if DAS score high enough
- If a joint is severely affected may need a joint replacement
What are the extra articular manifestations of RA?
- Scleritis
- Vasculitis
- Pleural effusion (exudative)
- Pulmonary fibrosis (also a complication of methotrexate)
- Neuropathy
- Amyloidosis (deposition of amyloid around the body)
- CKD
- Athersclerosis
- Peripheral neuropathy
- Anaemia
- Livedo reticularis
- Pyoderma gangrenosum
- Osteopenia
- Sjorgens
- Raynauds
What conditions are assoicated with RA?
Anaemia of chronic disease
Sjorgens (dry eyes and mouth occurs in 20% of RA patients)
Raynauds (more common in SLE and CREST)
How is disease activity assessed and how is it significant?
Disease activity index: (DAS)
- Raised ESR or CRP
- A no. of swollen joints
- A no. of tender joints
- Pain score (VAS)
Disease activity needs to be assessed before a patient can be started on an Anti TNF DAS >5.5
What is atlanto-axial subluxation?
How is it treated?
It is a complication of RA where the osteochondral destruction and cause laxity in the transverse ligament.
Occurs in 50% of those ith RA in C-spine
This allows subluxation of the odontoid peg anteriorly.
Presents with pain and deformity. MRI and X ray needed
Treated by surgical decompression of cord and stabilising C-spine
In which specialty is it very important to check for atalanto axial subluxation?
Anaesthetics.
Before theatre patient needs an extension flexion series of xrays. Head tilt can exacerbate subluxation and cause paralysis.
