Rheumatoid arthritis Flashcards
What is rheumatoid arthritis?
Common chronic inflammatory autoimmune disease
What does rheumatoid arthritis involve?
Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
Does rheumatoid arthritis tend to be symmetrical?
Yes
How does rheumatoid arthritis initially present?
A symmetrical, polyarticular inflammatory arthritis involving the small joints of the hands, wrists, and feet.
How can rheumatoid arthritis be differentiated from psoriatic arthritis?
The distal interphalangeal joints tend to be spared in rheumatoid arthritis and affected in psoriatic arthritis
Who is more commonly affected by rheumatoid arthritis?
Females
Smokers
What improves the pain in rheumatoid arthritis?
Movement
What can occur in the morning in someone with rheumatoid arthritis?
Prolonged early morning stiffness (more than 30minutes)
How can the joints appear on examination in someone with rheumatoid arthritis?
Joints are swollen, red, warm, and tender on examination.
What are 2 later signs of rheumatoid arthritis unlikely to be present on initial examination?
Swan neck
Boutonnière deformities
What test will be positive in someone with rheumatoid arthritis?
The squeeze test- discomfort on squeezing across the metacarpal or metatarsal joints
What are other possible presentations of rheumatoid arthritis?
acute onset with marked systemic disturbance
relapsing/remitting monoarthritis of different large joints
What are other possible presentations of rheumatoid arthritis?
acute onset with marked systemic disturbance
relapsing/remitting monoarthritis of different large joints
What is another term for relapsing/remitting monoarthritis of different large joints?
Palindromic rheumatism
What specific deformities of the hands are associated with rheumatoid arthritis?
Wrist subluxation.
Metacarpophalangeal (MCP) subluxation.
Swan-neck finger deformity
Boutonniere finger deformity
Ulnar deviation of proximal phalanges.
Z-shaped thumb.
What is swan neck deformity?
MCP flexion, PIP hyperextension, DIP hyperflexion
What is boutonniere finger deformity?
PIP flexion, DIP hyperextension
What specific deformities of the feet are associated with rheumatoid arthritis?
Hallux valgus.
Hammer toes.
MTP subluxation.
What early x-ray changes might you see in someone with rheumatoid arthritis?
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
What late x-ray changes might you see in someone with rheumatoid arthritis?
periarticular erosions
subluxation
What other joints can be affected in someone with rheumatoid arthritis?
Cervical spine
(lumbar and thoracic spine are usually spared)
Which part of the cervical spine is particularly affected in someone with rheumatoid arthritis?
Atlanto-axial joint (C1-C2).
How is the Atlanto-axial joint affected?
Stabilising ligaments of the joint are damaged, instability and subluxation of the Atlanto-axial joint can occur
What symptoms can Atlanto-axial subluxation result in?
Neck pain radiating to the occiput
Myelopathy resulting in weakness and altered sensation in the upper limbs
What are the possible peri-articular features of rheumatoid arthritis?
Carpal tunnel syndrome
Tenosynovitis
Bursitis
Where does tenosynovitis usually affect?
Flexor tendons in the hands, causing pain and swelling.
Where does the bursitis usually occur in someone with rheumatoid arthritis?
Olecranon (elbow) and sub-acromial (shoulder) bursae
Are patients with rheumatoid arthritis usually unwell?
Yes- Patients often feel generally unwell with RA, including low grade fevers, weight loss, and fatigue.
What haematological conditions are associated with rheumatoid arthritis?
Anaemia of chronic disease- common
Splenomegaly- Felty’s syndrome
Amyloidosis
Generalised lymphadenopathy.
What is Felty’s syndrome?
Triad of:
–Rheumatoid arthritis
–Splenomegaly
–Neutropenia
What is the most common ocular manifestation of rheumatoid arthritis?
Keratoconjunctivitis sicca (dry eyes)
(other: Episcleritis and scleritis)
What are the possible respiratory complications of rheumatoid arthritis?
Pulmonary fibrosis
Pleural effusions
Pulmonary nodules- Rheumatoid nodules
bronchiolitis obliterans-inflammation causing small airway destruction
What is bronchiolitis obliterans?
Inflammation causing small airway destruction
What respiratory complications can occur as a result of methotrexate?
Pneumonitis leading to pulmonary fibrosis
What cardiac complications can occur as a result of rheumatoid arthritis?
Ischaemic heart disease
Pericardial effusion
What is the first line antibody test for someone suspected of presenting with rheumatoid arthritis?
Rheumatoid factor
What is rheumatoid factor?
Circulating antibody (usually IgM)
How can rheumatoid factor be detected?
Rose-Waaler test
If a patient is negative for RF, what should they be tested for?
Anti-cyclic citrullinated peptide antibody (anti-CCP)
What is an advantage of testing for anti-CCP over RF?
Anti-CCP has a higher specificity for RA than RF
What other conditions are associated with a positive RF?
Felty’s syndrome
Sjogren’s syndrome
infective endocarditis
SLE
systemic sclerosis
What imaging should be carried out in all patients presenting with rheumatoid arthritis?
X-ray
What is used for monitoring disease activity and response to treatment?
DAS28 score (Disease Activity Score)
What is the DAS28 score based on?
The assessment for 28 joints and points are given for:
–Swollen joints
–Tender joints
–ESR/CRP result
What is the diagnostic criteria for rheumatoid arthritis from?
American College of Rheumatology (ACR)
What does the diagnostic criteria for rheumatoid arthritis involve?
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)
What features suggest a poor prognosis for rheumatoid arthritis?
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
What are the 2 main genetic associations with rheumatoid arthritis?
HLA DR4
HLA DR1
