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Musculoskeletal & Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Inflammation

A

Physiological response to deal with injury or infection

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2
Q

Inflammation clinical manifestation

A

Red (rubor)
Pain (dolor)
Hot (calor)
Swelling (tumour)
Loss of function

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3
Q

Gout

A

Syndrome caused by deposition of urate (uric acid) crystals -> inflammation

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4
Q

Gout risk factor

A

High uric acid level (hyperuricaemia)

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5
Q

Gout causes

A

Genetic tendency
Increased intake of purine rich foods
Reduced excretion (kidney failure)

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6
Q

Pseudogout

A

Syndrome caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystal deposition crystals -> inflammation

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7
Q

Gouty arthritis symptoms

A

Metatarsophalangeal joint of big joint
-abrupt onset
-extremely painful
-red, warm, swollen, tender
-resolves spontaneously over 3-10 days

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8
Q

Crystal arthritis signs

A

X-ray juxta-articular ‘rat bite’ erosions at metatarsophalangeal joint of great toe

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9
Q

Crystal arthritis investigation

A

Joint aspiration - synovial fluid analysis

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10
Q

Crystal arthritis management

A

Acute - colcihine, NSAIDS, steroids
Chronic - allopurinol

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11
Q

Synovial fluid examination for gout and pseudogout

A

Crystal- G: urate P: calcium pyrophosphate dihydrate (CPPD)

Shape- G: needle P: brick shaped

Birefringence- G: negative P: positive

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12
Q

Rheumatoid arthritis

A

Chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis of synovial joints

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13
Q

Rheumatoid arthritis pattern of involvement

A

Symmetrical
Affect multiple joints (polyarthritis)
Affect small and large joints, but particularly hands and feet

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14
Q

Rheumatoid arthritis commonest affected joints

A

Metacarpophalangeal joints
Proximal interphalangeal joints
Wrists
Knees
Ankles
Metatarsophalangeal joints

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15
Q

Psoriatic arthritis

A

Psoriasis is autoimmune disease affecting skin, 10% of patients also have joint inflammation

Rheumatoid factors not present (seronegative)

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16
Q

Psoriatic arthritis symptoms

A

Asymmetrical arthritis affecting IPJs

Can also be
Symmetrical involving small joints
Spinal and sacroiliac joint inflammation
Oligoarthritis of large joints
Arthritis mutilans

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17
Q

Psoriatic arthritis investigation

A

X-ray of affected joint - pencils in cup abnormality
MRI - sacroillitis and enthesis

Bloods - no autoantibodies

18
Q

Reactive arthritis

A

Sterile inflammation in joints following infection especially uro genital and gastrointestinal infections
May be first manifestation of HIV or hepatitis C infection
Symptoms follow 1-4 weeks after infection and this may be mild

19
Q

Reactive arthritis treatment

A

Usually self limiting
Can be managed with NSAIDS or DMARDs

20
Q

SLE epidemiology

A

F:M ratio 9:1
Presentation 15-40 years
Increased prevalence in African and Asian ancestry populations
Prevalence varies 4-280/100000

21
Q

Inflammation physiological changes

A

Increased blood flow
Migration of white blood cells (leukocytes) into the tissues
Activation/differentiation of leukocytes
Cytokine production

22
Q

Causes of joint inflammation

A

Crystal arthritis
-gout
-pseudogout

Immune-mediated (autoimmune)
-rheum arth
-seronegative spondyloarthropathies
-connective tissue disease

Infection
-septic arthritis
-tuberculosis

23
Q

Pseudogout risk factors

A

Background osteoarthritis
Elderly
Intercurrent infections

24
Q

Acute gout

A

Disease in which tissue deposition of monosodium urate (MSU) crystals occurs as a result of hyperuricaemia and leads to gouty arthritis or tophi

25
Q

Rheumatoid arthritis cause

A

Synovium becomes proliferated mass of tissue (pannus) due to:
-neovascularisation
-lymphangiogenesis
-inflammation cells - activated B and T cells, plasma cells, mast cells, activated macrophages

Excess of pro-inflammatory vs anti-inflammatory cytokines

26
Q

TNF alpha

A

Dominant pro-inflammatory cytokine in rheumatoid synovium

27
Q

TNF alpha effects

A

From activated macrophages:
-osteoclast activation
-angiogenesis
-proinflammatory cytokine release
-chemokine release

28
Q

Rheumatoid arthritis key features

A

Chronic arthritis
-polyarthritis - swelling of small joints of hand and wrist
-symmetrical
-early morning stiffness in and around joints
-joint erosion on radiograph

Extra-articular disease can occur
-rheumatoid nodules

Rheumatoid factor may be detected in blood
-autoantibody against IgG

29
Q

Rheumatoid arthritis extra Articular features

A

Common
-fever
-weight loss
-subcutaneous nodules

Uncommon
-vasculitis
-ocular inflammation
-neuropathy
-amyloidosis
-lung disease
-Felty’s syndrome

30
Q

Rheumatoid arthritis subcutaneous nodules

A

Central area of fibinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue

Associated with
-severe disease
-extra articular manifestations
-rheumatoid factor

Approx 30%

31
Q

Rheumatoid arthritis autoantibodies

A

Rheumatoid factor
-antibodies that recognise the Fc portion of IgG as their target antigen
-typically IgM antibodies: IgM anti-IgG antibody

Antibodies to citrullunated protein antigens (ACPA)
-arginine to citrulline

32
Q

Rheumatoid arthritis management

A

Requires early recognition of symptoms, referral and diagnosis, prompt initiation of treatment, aggressive treatment to suppress inflammation

Drugs:
-disease modifying anti rheumatic drugs (DMARDs)
-1st line - methotrexate in combo with hydroxychloroquine or sulfasalazine
-2nd line - biological therapy offer potent and targeted treatment strategy

33
Q

Rheumatoid arthritis biological therapies

A

Proteins that specifically target a protein such as an inflammatory cytokine

-inhibition of tumour necrosis factor alpha
-b cell depletion - rituximab
-modulation of T cell Co stimulation - abatacept
-inhibition of interleukin-6 signalling - tocilizumab

34
Q

Ankylosing spondylitis

A

Seronegative spondyloarthropathy - no positive autoantibodies
Chronic sacroillitis - inflammation of sacroiliac joints
Results in spinal fusion - ankylosis
Associated with HLA B27

35
Q

Ankylosing spondylitis common demographic

A

20-30 years old, male

36
Q

Ankylosing spondylitis symptoms

A

Lower back pain and stiffness
-early morning
-improves with exercise
Reduced spinal movements
Peripheral arthritis
Plantar Fasciitis, Achilles tendonitis
Fatigue
Hyperextended neck
Loss of lumbar lordosis
Flexed hips and knees

37
Q

Ankylosing spondylitis investigation

A

Blood
- normocytic anaemia
- raised CRP, ESR
- HLA B27

Imaging
-X Ray
-MRI
—squaring vertebra bodies, Romanus lesion
—erosion, sclerosis, narrowing SIJ
—bamboo spine
—bone marrow oedema

38
Q

Ankylosing spondylitis management

A

Physiotherapy
Exercise regime
NSAIDs
Peripheral joint disease - DMARDs

39
Q

Psoriatic arthritis management

A

DMARDs - methotrexate
Avoid oral steroids - risk of pustular psoriasis due to skin lesions

40
Q

Systemic Lupus Erythematous

A

Multi site inflammation
Antibodies to self antigen
Autoantibodies directed against components of cell nucleus (nucleus acids and proteins)

41
Q

SLE investigations

A

Antinuclear antibodies (ANA)
-high sensitivity to SLE but not specific
-negative rules out SLE

Anti double stranded DNA antibodies
-high specificity for SLE in context with clinical signs

Musculoskeletal & Rheumatology (7 decks)

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