Rheumatoid arthritis Flashcards
What is the pathogenesis for bony erosion in RA?
RANKL (in synovial fibroblasts and T-cells) binds RANK on osteoclasts
What is pathogenesis of RA?
- self-reactive CD4+ T-cells produced Th1 and Th17 cytokines—> cascade of inflammation
In RA, ___ and ____ form immune complexes inside joints–>activation of complement
- RF and anti-CCP antibodies
What causes the Majority of cutaneous findings in RA?
- neutrophil-mediated damage (as a result of complement activation)
Gene affected in RA?
- PTPN22
HLA assocation in RA:
HLA-DRB1
(patients with RA cant participate in the home run DRB1)
What is the diagnostic criteria for RA called?
- ACR/EULAR (see pg 116 for criteria)
rheumatoid nodules occur more commonly in RA patients with high _____ titers.
RF
How do rheumatoid nodules present clinically?
- firm, non-tender papules or nodules over bony prominences
What is rheumatoid nodulosis?
this is a variant of RA with:
- high RF
- multiple ulcerative rheumatoid nodules
-ABSENCE of active joint disease
Who gets therapy-induced rheumatoid nodulosis? How does it present?
- patients w/ preexisting RA following initiation of MTX or TNF-alpha inhibitor therapy
- Acute onset of numerous symmetrically grouped rheuymatoid nodules that are often PAINFUL (unlike normal rheumatoid nodules which are painless)
Rheumatoid vasculitis management:
- refer to rheum for aggressive therapy (high mortality up to 40%)
In what setting will you see Rheumatoid vasculitis?
- long standing history of erosive RA with high RF titer
What are Bywater’s lesions?
Purpuric papules usually on digital pulp seen in RA
If you see numerous atrophic, shiny, telangiectatic, yellow plaques w/ red-brown edges resembling NLD w/ ulceration on the lower extremities in RA patient, this is_____
superficial ulcerating necrobiosis (aka rheumatoid necrobiosis)
- occurs in severe RA w/ high RF titer
What neutrophilic dermatoses are seen in RA patients?
- Swets
- Erythema elevatum diutinum
- PG
- MTX-induced papular eruption
- Palisaded neutrophilic granulomatous dermatitis
- Interstitial granulomatous dermatitis
How does rheumatoid neutrophilic dermatitis present?
persistent urticarial red papules/plaques symmetrically distributed on extensor forearms and hands
- these may represent earliest face of rheumatoid nodules
How does interstitial granulomatous dermatitis w/ arthritis present?
- Annular red-violaceous plaques on trunk and intertriginous areas, sometimes with “rope sign” (red-flesh colored cords extending down flanks or back)
- seen in patients with RA (if without arthritis is simply IGD)
Histopath of rheumatoid nodules, early and late:
early: interstitial granulomatous or neutrophilic infiltrate
late: large palisading granulomas surrounding degenerated eosinophilic connective tissue (“necrobiosis”) and Fibrin
Tx for acute flare of RA?
steroids (as a bridge to DMARD)
First line long term therapy for RA? Second line?
MTX (also can use sulfasalzine, hydroxychloroquine, and leflunomide) + NSAIDS
- second line is biologics (TNF-AI)
How to treat rheumatoid nodules?
- can try intralesional CS or excision (recurrence common)
do not respond to treatment of arthritis
Prognosis of RA?
- chronic progressive disease activity that waxes and wanes over time
Mortality rate compared to general population in RA patients? Most common cause of death in RA?
- two times higher mortality than general population
Ischemic heart disease
What is Felty syndrome?
RA w/:
- neutropenia
- splenomegaly
- refractory leg ulcers (resembling PG)
