Rheumatoid Arthritis Flashcards by Hannah Brule

Is rheumatoid arthritis inflammatory?

Yes

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Rheumatoid arthritis is characterized by an ___ response

osteolytic
(degenerative is osteoblastic)

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What is ankylosis?

Joint fusion/adhesion

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Is ankylosis seen in rheumatoid arthritis or in degenerative joint disease?

Rheumatoid arthritis

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Joint fusion as seen in rheumatoid arthritis can be fibrous or osseous, creating which protein?

Fibrin

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Why does chronic rheumatoid arthritis lead to anemia?

Marrow fibrosis

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If an inflammatory condition is bilateral or symmetrical, it is likely ___

systemic

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If rheumatoid arthritis is seen in an x-ray, how long has the disease been present?

A long time (2-7 years)

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What is the most common inflammatory arthropathy?

Rheumatoid arthritis

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When in life does rheumatoid arthritis most commonly start?

20s-30s but can occur at any age

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Rheumatoid arthritis generally affects ___ joints first and moves to ___

smaller joints first and moves to larger joints

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The spine is rarely affected early in rheumatoid arthritis, but nearly 80% of patients will eventually experience ___ involvement

cervical

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Why does rheumatoid arthritis more commonly affect cervical spine than other areas of the spine?

Cervical spine has smaller joints, can lead to destruction of transverse ligament and instability

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If joint changes occur at the metacarpophalangeal joints, is it more likely to be rheumatoid arthritis or degenerative joint disease?

Rheumatoid arthritis
(DJD doesn’t like MCP)

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What are some systemic manifestations of rheumatoid arthritis?

Emphysema (without smoking)
Pericarditis
Vasculitis
Liver/renal fibrosis

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A patient has rheumatoid arthritis and experiences systemic manifestations including vasculitis.

How does this vasculitis present?
What is the risk of this?

Painful rashes, pain in hands/feet
Narrow lumen (vasospasm)
Increased risk of heart attack and stroke

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Systemic manifestations of rheumatoid arthritis can be life threatening but come in varying degrees.
What pattern do these manifestations tend to take?

Exacerbation/remission pattern

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As much as 50% of risk of rheumatoid arthritis is attributed to ___

genetic factors

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What are the genetic factors leading to rheumatoid arthritis?

HLA-DRB1 (human leukocyte antigen)
PTPN22 (deficient in RA)

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How does HLA-DRB1 contribute to rheumatoid arthritis?

Involved in location of presumed binding site for the arthritogens that initiate inflammation
Abnormal in the case of RA

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How does PTPN22 contribute to rheumatoid arthritis?

Normally encodes protein tyrosine phosphate which inhibits T-cell activation
Deficient in the case of RA

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What are some environmental risk factors/possible causes that could activate the arthritogen for rheumatoid arthritis to occur?

Infection
Smoking (decreased collagen formation)
Epstein-Barr virus (not proven)

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rheumatoid arthritis

___ (cells) may initiate autoimmune response by reacting with arthritogenic agent

CD4+ T helper cells

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rheumatoid arthritis

During the initial autoimmune response, what cells can be found in the joints?

Cytokines:

IFN-y
IL-7
TNF and IL-1
IL-1, PGE2, and RANKL

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#rheumatoid arthritis During the initial autoimmune response, cytokine, IFN-y can be found in the joints. What is the function of this cytokine?

Activate macrophages and resident synovial cells (A synoviocytes)

#rheumatoid arthritis During the initial autoimmune response, cytokine, IL-7 can be found in the joints. What is the function of this cytokine?

Signal neutrophils and monocytes

#rheumatoid arthritis During the initial autoimmune response, cytokines, TNF and IL-1 can be found in the joints. What is the shared function of these cytokines?

Stimulate synovial cells to secrete proteases (which destroy hyaline cartilage uniformly)

#rheumatoid arthritis During the initial autoimmune response, cytokines, IL-1, PGE2, and RANKL can be found in the joints. What is the shared function of these cytokines?

Stimulate osteoclasts and bone resorption (leading to periarticular osteopenia)

What are the four steps in pathogenesis of rheumatoid arthritis? What are the two uncommon/rare steps?

1. Autoimmune response 2. Synovial hyperplasia and hypertrophy 3. Pannus proliferation 4. Cartilage and bone destruction 5. Fibrous ankylosis (uncommon) 6. Bony ankylosis (rare)

#rheumatoid arthritis During synovial hyperplasia and hypertrophy, ___ and ___ cells accumulate in synovium

lymphocytes and plasma cells

#rheumatoid arthritis The synovium is ___ cell layers thick

2-3 cell layers thick

#rheumatoid arthritis With chronically inflamed synovium, there is ___ proliferation

pannus

#rheumatoid arthritis During pannus proliferation, ___ increase in the joint which increase ___ of the synovium

**enzymes and proteases** increase in the joint which increase **vascularity** of the synovium

#rheumatoid arthritis During pannus proliferation, what are the immediate consequences of increase in vascularity?

* Hemorrhage and increased hemosiderin * Brings small fibrin nodules which float in the joint space (rice bodies)

What are rice bodies?

Small fibrin nodules which float in the joint space found during pannus proliferation of rheumatoid arthritis

#rheumatoid arthritis The pannus covers ___ and separates it from ___

covers the **articular cartilage** and separates it from **synovial fluid**

#rheumatoid arthritis What is the immediate consequence of the pannus covering the articular cartilage, separating it from synovial fluid?

There is less diffusion, starving the cartilage

#rheumatoid arthritis What symptoms arise as the pannus eventually fills the entire joint space?

Joint stiffness, decreased range of motion, achiness (due to inflammation)

A patient has rheumatoid arthritis and the pannus has filled the entire joint space. How does it appear histologically?

"Frond-like" (fern-like) appearance

#rheumatoid arthritis Proteases destroy ___

hyaline cartilage

Why does rheumatoid arthritis lead to uniform joint space loss?

Synovium secretes chondrolytic enzymes, so joint space loss is chemically mediated

In the pathogenesis of rheumatoid arthritis, which cytokines are responsible for bone destruction and resorption?

* RANKL * PGE2 * IL-1 | stimulate osteoclasts

#rheumatoid arthritis How does cartilage and bone destruction lead to subluxations and dislocations?

* Ligamentous attachment sites may be lost destabilizing joints * Tendon sheathes (synovium) can rupture (very thin) or subluxate causing bone misalignment

What color should synovial fluid be? How does it appear with rheumatoid arthritis?

Should be yellow/clear Raw bloody bone with RA

What is the nature of the onset of rheumatoid arthritis?

Gradual onset characterized by remissions and exacerbations

Where in the body is rheumatoid arthritis most likely to appear?

* Metacarpophalangeal joints (proximal) * Interphalangeal joints * Metatarsophalangeal joints * Cervical spine * Elbow * Knee * Ankle (does not prefer DIP)

A patient presents with the following: * Warm, swollen, painful, metacarpophalangeal and wrist joints * Pain increased by motion * Pain worse after periods of disuse (lasting longer than degenerative stiffness) * Flexion and extension deformities in fingers * Crepitus * Fatigue What is the likely diagnosis?

Rheumatoid arthritis

A patient presents with the following: * Warm, swollen, painful metatarsophalangeal and ankle joints bilaterally * Pain increased by motion * Pain worse after periods of disuse * Inflamed olecranon processes bilaterally * Swollen wrists with limited ROM * Evidence of acute necrotizing vasculitis (ankle ulcers) What is the likely diagnosis?

Rheumatoid arthritis

Rheumatoid nodules occur in about 25% of cases and are generally associated with ___

more severe disease expression of rheumatoid arthritis

#rheumatoid arthritis Where do rheumatoid nodules occur?

Can occur in skin and sometimes visceral organs Elbow and legs are common sites

If a patient presents with ligament attachment destruction (subluxations) and tenosynovitis in their hands, what is the likely diagnosis?

Rheumatoid arthritis

Is tenosynovitis more likely to occur with DJD or rheumatoid arthritis?

Rheumatoid arthritis

#rheumatoid arthritis What are some clinical manifestations of acute necrotizing vasculitis?

* Inflammation of the blood vessels * Vascular narrowing * Impaired blood flow to tissues * Ischemia and necrosis

What are some grossly visible examples of acute necrotizing vasculitis suggesting rheumatoid arthritis?

Conjunctivitis and/or ulcers

What percentage of rheumatoid arthritis patients experience this severe of deformity?

<10%

What is another name for swan neck deformity?

Arthritis mutilans

What is another name for arthritis mutilans?

Swan neck deformity

If a patient presents with swan neck deformity in their digits, what diagnoses comes to mind?

* Rheumatoid arthritis * Psoriatic arthritis

What are the expected ESR and C-reactive protein levels for rheumatoid arthritis?

Elevated ESR (RBCs settle to bottom faster) Elevated C-reactive protein

Is elevated ESR more valuable if positive or negative?

More valuable if negative If positive, need to get additional labs

80% of rheumatoid arthritis patients test positive for ___

Rheumatoid factor (RF) (Sensitive test)

What is rheumatoid factor?

Seropositive factor representing multiple antibodies: IgM, IgG, or directed against the Fc fragment of IgG | positive for those with rheumatoid arthritis

2/3 of rheumatoid arthritis patients test positive for ___

Anticitrullinated protein antibody (ACPA) (Less sensitive, more specific test than RF)

Are rheumatoid arthritis radiographic findings bilateral or unilateral?

Bilateral and symmetrical in their degree of joint dysfunction

With rheumatoid arthritis, osteolytic lesions are found ___

at the joint margins (juxta-articular): * marginal erosion * periarticular osteopenia * colloquially "rat bit" lesions

A patient's wrist radiograph shows uniform loss of joint space, juxta-articular osteoporosis, and pseudocysts. What is diagnosis comes to mind?

Rheumatoid arthritis

What is the general radiographic presentation of rheumatoid arthritis?

* Bilateral, symmetrical presentation * Osteolytic lesions at joint margins * Juxta-articular osteoporosis * Uniform loss of joint space * Pseudocysts * Deformities

How does rheumatoid arthritis present in cervical spine radiographs?

* Facets destroy capsule leading to **stair-step appearance** (spondylolisthesis) * Increased atlanto-dental interspace due to transverse ligament laxity (atlanto-axial joint)

Why do we see anterolisthesis of the cervical spine with rheumatoid arthritis?

Ligament laxity/instability

What makes a patient eligible to assess for classifying definite rheumatoid arthritis?

More than ten joints, including at least one small joint, that are symptomatic

#2010 RA classification If a patient has more than ten joints, including one small joint, that are symptomatic and test positive for RF factor, do they have rheumatoid arthritis?

Yes

#2010 RA classification If a patient has more than ten joints, including two small joints, that are symptomatic, but test negative for RF factor, what additional conditions would mean they still have rheumatoid arthritis?

* Duration of symptoms longer than 26 weeks * Abnormal APR (increased CRP/ESR)

What are three modalities of treatment for rheumatoid arthritis?

* Activity * Diet * Drug therapy

What sort of activity is appropriate for a patient with rheumatoid arthritis?

Low impact, regular activity

What sort of diet is appropriate for a patient with rheumatoid arthritis?

Anti-inflammatory diet

What sort of drug therapies are appropriate for varying degrees of rheumatoid arthritis?

Mild: NSAIDs Severe short-term use: corticosteroid (prednisone) Severe long-term use: disease modifying antirheumatic drugs (DMARDs)

For long-term drug therapy of rheumatoid arthritis, what are some examples of disease modifying antirheumatic drugs (DMARDs)?

* Methotrexate (hard on liver, must check liver labs) * TNF antagonists * T-cell costimulatory blockers * B-cell depleting agents * IL-1 receptor antagonists

Why don't we use prednisone long-term for rheumatoid arthritis?

Corticosteroids lower immune system, may lead to Cushing

How common is rheumatoid arthritis?

1-2% of adult population in the U.S. is affected (very common)