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Musculoskeletal Physiopathology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Is rheumatoid arthritis inflammatory?

A

Yes

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2
Q

Rheumatoid arthritis is characterized by an ___ response

A

osteolytic
(degenerative is osteoblastic)

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3
Q

What is ankylosis?

A

Joint fusion/adhesion

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4
Q

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

A

Rheumatoid arthritis

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5
Q

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

A

Fibrin

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6
Q

Why does chronic rheumatoid arthritis lead to anemia?

A

Marrow fibrosis

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7
Q

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

A

systemic

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8
Q

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

A

A long time (2 years)

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9
Q

What is the most common inflammatory arthropathy?

A

Rheumatoid arthritis

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10
Q

When in life does rheumatoid arthritis most commonly start?

A

20s-30s but can occur at any age

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11
Q

Rheumatoid arthritis generally affects ___ joints first and moves to ___

A

smaller joints first and moves to larger joints

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12
Q

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

A

cervical

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13
Q

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

A

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

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14
Q

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

A

Rheumatoid arthritis
(DJD doesn’t like MCP)

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15
Q

What are some systemic manifestations of rheumatoid arthritis?

A
  • Emphysema (without smoking)
  • Pericarditis
  • Vasculitis
  • Liver/renal fibrosis
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16
Q

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

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

A
  • Painful rashes, pain in hands/feet
  • Narrow lumen (vasospasm)
  • Increased risk of heart attack and stroke
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17
Q

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

A

Exacerbation/remission pattern

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18
Q

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

A

genetic factors

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19
Q

What are the genetic factors leading to rheumatoid arthritis?

A
  • HLA-DRB1 (human leukocyte antigen)
  • PTPN22 (deficient in RA)
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20
Q

How does HLA-DRB1 contribute to rheumatoid arthritis?

A

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

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21
Q

How does PTPN22 contribute to rheumatoid arthritis?

A

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

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22
Q

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

A
  • Infection
  • Smoking (decreased collagen formation)
  • Epstein-Barr virus (not proven)
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23
Q

rheumatoid arthritis

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

A

CD4+ T helper cells

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24
Q

rheumatoid arthritis

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

A

Cytokines:

  • IFN-y
  • IL-7
  • TNF and IL-1
  • IL-1, PGE2, and RANKL
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25
Q

rheumatoid arthritis

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

A

Activate macrophages and resident synovial cells

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26
Q

rheumatoid arthritis

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

A

Signal neutrophils and monocytes

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27
Q

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?

A

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

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28
Q

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?

A

Stimulate osteoclasts and bone resorption

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29
Q

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

A
  1. Autoimmune response
  2. Synovial hyperplasia and hypertrophy
  3. Pannus proliferation
  4. Cartilage and bone destruction
  5. Fibrous ankylosis (uncommon)
  6. Bony ankylosis (rare)
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30
Q

rheumatoid arthritis

During synovial hyperplasia and hypertrophy, ___ and ___ cells accumulate in synovium

A

lymphocytes and plasma cells

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31
Q

rheumatoid arthritis

The synovium is ___ cell layers thick

A

2-3 cell layers thick

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32
Q

rheumatoid arthritis

With chronically inflamed synovium, there is ___ proliferation

A

pannus

33
Q

rheumatoid arthritis

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

A

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

34
Q

rheumatoid arthritis

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

A
  • Hemorrhage and increased hemosiderin
  • Brings small fibrin nodules which float in the joint space (rice bodies)
35
Q

What are rice bodies?

A

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

36
Q

rheumatoid arthritis

The pannus covers ___ and separates it from ___

A

covers the articular cartilage and separates it from synovial fluid

37
Q

rheumatoid arthritis

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

A

There is less diffusion, starving the cartilage

38
Q

rheumatoid arthritis

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

A

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

39
Q

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

A

“Frond-like” (fern-like) appearance

40
Q

rheumatoid arthritis

Proteases destroy ___

A

hyaline cartilage

41
Q

Why does rheumatoid arthritis lead to uniform joint space loss?

A

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

42
Q

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

A
  • RANKL
  • PGE2
  • IL-1

stimulate osteoclasts

43
Q

rheumatoid arthritis

As cartilage and bone is destroyed, what are the consequences of subluxations and dislocations?

A
  • Ligamentous attachment sites may be lost destabilizing joints
  • Tendon sheathes (synovium) can rupture (very thin) or subluxate causing bone misalignment
44
Q

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

A

Should be yellow/clear
Raw bloody bone with RA

45
Q

What is the nature of the onset of rheumatoid arthritis?

A

Gradual onset characterized by remissions and exacerbations

46
Q

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

A
  • Metacarpophalangeal joints (proximal)
  • Interphalangeal joints
  • Metatarsophalangeal joints
  • Cervical spine
  • Elbow
  • Knee
  • Ankle

(does not prefer DIP)

47
Q

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?

A

Rheumatoid arthritis

48
Q

A patient presents with the following:

  • Warm, swollen, painful metatarsophalangeal and ankle joints
  • Pain increased by motion
  • Pain worse after periods of disuse
  • Inflamed olecranon process
  • Evidence of acute necrotizing vasculitis (conjunctivitis and ankle ulcers)

What is the likely diagnosis?

A

Rheumatoid arthritis

49
Q

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

A

more severe disease expression of rheumatoid arthritis

50
Q

rheumatoid arthritis

Where do rheumatoid nodules occur?

A

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

51
Q

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

A

Rheumatoid arthritis

52
Q

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

A

Rheumatoid arthritis

53
Q

rheumatoid arthritis

What are some clinical manifestations of acute necrotizing vasculitis?

A
  • Inflammation of the blood vessels
  • Vascular narrowing
  • Impaired blood flow to tissues
  • Ischemia and necrosis
54
Q

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

A

Conjunctivitis and/or ulcers

55
Q

Which rheumatoid arthritis deformation is less common in industrialized countries?

A

Arthritis deformans (<10% get this severe)

56
Q

What is another name for swan neck deformity?

A

Arthritis mutilans

57
Q

What is another name for arthritis mutilans?

A

Swan neck deformity

58
Q

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

A

Rheumatoid arthritis

59
Q

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

A

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

60
Q

Is elevated ESR more valuable if positive or negative?

A

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

61
Q

80% of rheumatoid arthritis patients test positive for ___

A

Rheumatoid factor (RF)
(Sensitive test)

62
Q

What is rheumatoid factor?

A

Seropositive factor representing multiple antibodies: IgM, IgG, or directed against the Fc fragment of IgG

positive for those with rheumatoid arthritis

63
Q

2/3 of rheumatoid arthritis patients test positive for ___

A

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

64
Q

Are rheumatoid arthritis radiographic findings bilateral or unilateral?

A

Bilateral and symmetrical in their degree of joint dysfunction

65
Q

With rheumatoid arthritis, osteolytic lesions are found ___

A

at the joint margins (juxta-articular):

  • marginal erosion
  • periarticular osteopenia
  • colloquially “rat bit” lesions
66
Q

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

A

Rheumatoid arthritis

67
Q

What is the general radiographic presentation of rheumatoid arthritis?

A
  • Bilateral, symmetrical presentation
  • Osteolytic lesions at joint margins
  • Juxta-articular osteoporosis
  • Uniform loss of joint space
  • Pseudocysts
  • Deformities
68
Q

How does rheumatoid arthritis present in cervical spine radiographs?

A
  • Facets destroy capsule leading to stair-step appearance (spondylolisthesis)
  • Increased atlanto-dental interspace due to transverse ligament laxity (atlanto-axial joint)
69
Q

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

A

Ligament laxity/instability

70
Q

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

A

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

71
Q

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?

A

Yes

72
Q

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?

A
  • Duration of symptoms longer than 26 weeks
  • Abnormal APR (increased CRP/ESR)
73
Q

What are three modalities of treatment for rheumatoid arthritis?

A
  • Activity
  • Diet
  • Drug therapy
74
Q

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

A

Low impact, regular activity

75
Q

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

A

Anti-inflammatory diet

76
Q

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

A

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

77
Q

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

A
  • Methotrexate (hard on liver, must check liver labs)
  • TNF antagonists
  • T-cell costimulatory blockers
  • B-cell depleting agents
  • IL-1 receptor antagonists
78
Q

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

A

Corticosteroids lower immune system, may lead to Cushing

Musculoskeletal Physiopathology (32 decks)

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