Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

• autoimmune disease associated with antibodies to Fc portion of IgG (rheumatoid actor) + anti-CCP (citrullinated cyclic peptide)
• causing chronic inflammation in synovial lining of joints

Question 2

What is the pathogenesis of rheumatoid arthritis?

Answer 2

• citrullination of self antigens
• these are recognised by T+B cells > antibody production (RF + anti-CCP)
• stimulates macrophages + fibroblasts release TNFa
• proliferation of synoviocytes which grow over cartilage
• causing restriction of nutrients + damage to cartridge
• activated macrophages stimulates osteoclast differentiation > bone damage

Question 3

Typical history of rheumatoid arthritis

Answer 3

• female
• 30-50 years old
• progressive, peripheral + symmetrical polyarthritis
• affecting MCPs/PIPs/MTPs + spares DIP
• history of >6 weeks for morning stiffness >30mins duration
• joint pain, stiffness + swelling
• fatigue

Question 4

Risk factors for rheumatoid arthritis

Answer 4

• female
• smoking
• family history
• obesity

Question 5

What is the pattern of rheumatoid arthritis?

Answer 5

Symmetrical polyarthritis

Question 6

What joints does rheumatoid arthritis often affect?

Answer 6

MCP
PIP
MTP

Question 7

What large joints can rheumatoid arthritis affect?

Answer 7

Ankle
Knee
Hips
Shoulders
C spine

Question 8

What is found in examination of rheumatoid arthritis?

Answer 8

• Z shaped thumb deformity
• ulnar deviation/palmar subluxation of MCPs
• swan-neck + boutonnière deformity of digits
• rheumatoid nodules (often at elbow)
• check median nerve - carpal tunnel association

Question 9

What is swan neck deformity?

Answer 9

Hyperextended PIP
Flexed DIP

Question 10

What is boutonnière deformity?

Answer 10

Hyperextended DIP
Flexed PIP

Question 11

Investigations of rheumatoid arthritis

Answer 11

• X ray for established disease
• USS/MRI for early disease
• RF + anti-CCP
• FBC - normocytic anaemia
• inflammatory markers (CRP)

Question 12

X ray features of rheumatoid arthritis

Answer 12

LESS
- Loss of joint space
- Erosions
- Soften tissue swelling
- Subluxation
- (see through bones - osteopenia)

Question 13

Treatment of rheumatoid arthritis

Answer 13

• initially DMARD monotherapy - methotrexate
• consider combination DMARDs - hydroxycholorquine, sulfasalazine, leflunomide
• if still severe then consider biologics - anti-TNFs e.g. etanercept
• steroids (acutely)
• NSAIDs for symptoms control with PPI cover
• Physiotherapy + occupational therapy

Question 14

What DMARDs are safe in pregnancy + which are teratogenic?

Answer 14

Hydroxychloroquine + sulfasalazine are SAFE
Methotrexate + leflunomide are TERATOGENIC

Question 15

Who are extra-articular manifestations of rheumatoid arthritis mainly in?

Answer 15

RF+ patients with severe articular disease

Question 16

What are extra-articular manifestations of rheumatoid arthritis?

Answer 16

CAPS
- Carpal tunnel syndrome
- Anaemia of chronic disease, Amyloidosis, Atlkantoaxial involvement
- Pulmonary fibrosis, Pulmonary nodules, Pleruisy, Pleural effusion
- Sjogren’s syndrome, Splenomegaly (Felty’s syndrome)

Question 17

How can rheumatoid arthritis cause spinal cord compression?

Answer 17

• Synovitis + damage to ligaments around odontoid peg of C2
• this allows C2 to shift within A1
• causes atlantoaxial subluxation
• this can cause spinal cord compression

Question 18

What is Felty’s syndrome compromised of?

Answer 18

RA
Neutropenia
Splenomegaly