Rheumatoid arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Common chronic inflammatory autoimmune disease

Question 2

What does rheumatoid arthritis involve?

Answer 2

Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

Question 3

Does rheumatoid arthritis tend to be symmetrical?

Answer 3

Yes

Question 4

How does rheumatoid arthritis initially present?

Answer 4

A symmetrical, polyarticular inflammatory arthritis involving the small joints of the hands, wrists, and feet.

Question 5

How can rheumatoid arthritis be differentiated from psoriatic arthritis?

Answer 5

The distal interphalangeal joints tend to be spared in rheumatoid arthritis and affected in psoriatic arthritis

Question 6

Who is more commonly affected by rheumatoid arthritis?

Answer 6

Females
Smokers

Question 7

What improves the pain in rheumatoid arthritis?

Answer 7

Movement

Question 8

What can occur in the morning in someone with rheumatoid arthritis?

Answer 8

Prolonged early morning stiffness (more than 30minutes)

Question 9

How can the joints appear on examination in someone with rheumatoid arthritis?

Answer 9

Joints are swollen, red, warm, and tender on examination.

Question 10

What are 2 later signs of rheumatoid arthritis unlikely to be present on initial examination?

Answer 10

Swan neck
Boutonnière deformities

Question 11

What test will be positive in someone with rheumatoid arthritis?

Answer 11

The squeeze test- discomfort on squeezing across the metacarpal or metatarsal joints

Question 12

What are other possible presentations of rheumatoid arthritis?

Answer 12

acute onset with marked systemic disturbance
relapsing/remitting monoarthritis of different large joints

Question 12

What are other possible presentations of rheumatoid arthritis?

Answer 12

acute onset with marked systemic disturbance
relapsing/remitting monoarthritis of different large joints

Question 13

What is another term for relapsing/remitting monoarthritis of different large joints?

Answer 13

Palindromic rheumatism

Question 14

What specific deformities of the hands are associated with rheumatoid arthritis?

Answer 14

Wrist subluxation.
Metacarpophalangeal (MCP) subluxation.
Swan-neck finger deformity
Boutonniere finger deformity
Ulnar deviation of proximal phalanges.
Z-shaped thumb.

Question 15

What is swan neck deformity?

Answer 15

MCP flexion, PIP hyperextension, DIP hyperflexion

Question 16

What is boutonniere finger deformity?

Answer 16

PIP flexion, DIP hyperextension

Question 17

What specific deformities of the feet are associated with rheumatoid arthritis?

Answer 17

Hallux valgus.
Hammer toes.
MTP subluxation.

Question 18

What early x-ray changes might you see in someone with rheumatoid arthritis?

Answer 18

loss of joint space
juxta-articular osteoporosis
soft-tissue swelling

Question 19

What late x-ray changes might you see in someone with rheumatoid arthritis?

Answer 19

periarticular erosions
subluxation

Question 20

What other joints can be affected in someone with rheumatoid arthritis?

Answer 20

Cervical spine
(lumbar and thoracic spine are usually spared)

Question 21

Which part of the cervical spine is particularly affected in someone with rheumatoid arthritis?

Answer 21

Atlanto-axial joint (C1-C2).

Question 22

How is the Atlanto-axial joint affected?

Answer 22

Stabilising ligaments of the joint are damaged, instability and subluxation of the Atlanto-axial joint can occur

Question 23

What symptoms can Atlanto-axial subluxation result in?

Answer 23

Neck pain radiating to the occiput
Myelopathy resulting in weakness and altered sensation in the upper limbs

Question 24

What are the possible peri-articular features of rheumatoid arthritis?

Answer 24

Carpal tunnel syndrome Tenosynovitis Bursitis

Question 25

Where does tenosynovitis usually affect?

Answer 25

Flexor tendons in the hands, causing pain and swelling.

Question 26

Where does the bursitis usually occur in someone with rheumatoid arthritis?

Answer 26

Olecranon (elbow) and sub-acromial (shoulder) bursae

Question 27

Are patients with rheumatoid arthritis usually unwell?

Answer 27

Yes- Patients often feel generally unwell with RA, including low grade fevers, weight loss, and fatigue.

Question 28

What haematological conditions are associated with rheumatoid arthritis?

Answer 28

Anaemia of chronic disease- common Splenomegaly- Felty's syndrome Amyloidosis Generalised lymphadenopathy.

Question 29

What is Felty's syndrome?

Answer 29

Triad of: --Rheumatoid arthritis --Splenomegaly --Neutropenia

Question 30

What is the most common ocular manifestation of rheumatoid arthritis?

Answer 30

Keratoconjunctivitis sicca (dry eyes) (other: Episcleritis and scleritis)

Question 31

What are the possible respiratory complications of rheumatoid arthritis?

Answer 31

Pulmonary fibrosis Pleural effusions Pulmonary nodules- Rheumatoid nodules bronchiolitis obliterans-inflammation causing small airway destruction

Question 32

What is bronchiolitis obliterans?

Answer 32

Inflammation causing small airway destruction

Question 33

What respiratory complications can occur as a result of methotrexate?

Answer 33

Pneumonitis leading to pulmonary fibrosis

Question 34

What cardiac complications can occur as a result of rheumatoid arthritis?

Answer 34

Ischaemic heart disease Pericardial effusion

Question 35

What is the first line antibody test for someone suspected of presenting with rheumatoid arthritis?

Answer 35

Rheumatoid factor

Question 36

What is rheumatoid factor?

Answer 36

Circulating antibody (usually IgM)

Question 37

How can rheumatoid factor be detected?

Answer 37

Rose-Waaler test

Question 38

If a patient is negative for RF, what should they be tested for?

Answer 38

Anti-cyclic citrullinated peptide antibody (anti-CCP)

Question 39

What is an advantage of testing for anti-CCP over RF?

Answer 39

Anti-CCP has a higher specificity for RA than RF

Question 40

What other conditions are associated with a positive RF?

Answer 40

Felty's syndrome Sjogren's syndrome infective endocarditis SLE systemic sclerosis

Question 41

What imaging should be carried out in all patients presenting with rheumatoid arthritis?

Answer 41

X-ray

Question 42

What is used for monitoring disease activity and response to treatment?

Answer 42

DAS28 score (Disease Activity Score)

Question 43

What is the DAS28 score based on?

Answer 43

The assessment for 28 joints and points are given for: --Swollen joints --Tender joints --ESR/CRP result

Question 44

What is the diagnostic criteria for rheumatoid arthritis from?

Answer 44

American College of Rheumatology (ACR)

Question 45

What does the diagnostic criteria for rheumatoid arthritis involve?

Answer 45

The joints that are involved (more and smaller joints score higher) Serology (rheumatoid factor and anti-CCP) Inflammatory markers (ESR and CRP) Duration of symptoms (more or less than 6 weeks)

Question 46

What features suggest a poor prognosis for rheumatoid arthritis?

Answer 46

rheumatoid factor positive anti-CCP antibodies poor functional status at presentation X-ray: early erosions (e.g. after < 2 years) extra articular features e.g. nodules HLA DR4 insidious onset

Question 47

What are the 2 main genetic associations with rheumatoid arthritis?

Answer 47

HLA DR4 HLA DR1