Rheumatoid Arthritis

Question 1

What is the etiology of rheumatoid arthritis?

Answer 1

idiopathic inflammatory autoimmune

- genetic predisposition -> HLA-DR4 & HLA-DR1

Question 2

What is the pathophysiology of rheumatoid arthritis?

Answer 2

1- citrullinated proteins recognized as foreign bodies
2- production of anticitrullinated peptide antibodies
3- IgM against Fc portion of IgG form immune complex (rheumatoid factor)

Question 3

What are the articular manifestations of rheumatoid arthritis?

Answer 3

1- polyarthralgia

• symmetrical pain & swelling
• MCP & PIP most commonly affected

2- morning stiffness -> more than 30 mins & improves with activity

3- joint deformities

• boutonnière
• swan neck
• Z deformity (hitchhiker)
• ulnar deviation
• piano key sign
• hammer toe or claw toe
• baker cyst

4- atlantoaxial subluxation -> could lead to cord compression

Question 4

What are the extra-articular manifestations of rheumatoid arthritis?

Answer 4

• subcutaneous rheumatoid arthritis
• lungs -> pleuritis, pleural effusion
• eye -> keratoconjunctivitis sicca, scleritis, episcleritis
• normocytic anemia
• heart -> pericarditis, myocarditis, increased risk of MI
• peripheral vasculitis
• secondary sjogren syndrome
• carpal tunnel syndrome

Question 5

What are the indications for synovial fluid analysis?

Answer 5

• suspicion of septic arthritis

- atypical presentation to rule out DD

Question 6

What is the best initial study for rheumatoid arthritis?

Answer 6

XRAY will show

• joint space narrowing
• marginal erosions of cartilage & bone
• osteopenia
• subchondral cysts

Question 7

How is RA managed?

Answer 7

1- ACUTE FLARES

• NSAIDs
• steroids

2- Long term management
- DMARDs (methotrexate)

3- Non pharmacological management

• ASCVD prevention measures
• physical & occupational therapy

4- Surgical treatment

• in case of severe joint deformity
• symptoms not controlled by medical treatment

Question 8

What are the side effects of methotrexate?

Answer 8

• myelosuppression
• hepatotoxicity
• cirrhosis

(give folic acid to prevent toxicity)

Question 9

What should be added to long term management in case methotrexate was not effective?

Answer 9

add TNF-a inhibitors after 3 - 6 months

• infliximab
• adalimumab
• etanercept
• certolizumab

Question 10

What are the complications of rheumatoid arthritis?

Answer 10

• upper & lower limb deformities
• muscle weakness -> Baker’s cyst
• vasculitis involving the kidney
• AA amyloidosis
• septic arthritis
• osteopenia, osteoporosis, bone fractures