Rheumatoid Arthritis

Question 1

Characteristic findings of RA

Answer 1

Symmetric poly arthritis involving mainly small joints of hands or feet
Morning stiffness lasting >1 hr
Sites of involvement(PIP, MCP, wrist, elbow, knee, ankle, and MTP)
Synovitis characterized by soft tissue swelling or effusion
Subq nodules over bony prominences or extensor surfaces

Question 2

Lab findings

Answer 2

Positive RF(sensitivity 80%, specificity 87%)
Elevated ESR or CRP
Normocytic anemia
+anti-CCP(sensitivity 76%, specificity 96%)

Question 3

Common RA mimics

Answer 3

• skin rash + leukopenia-> SLE
• psoriasis or pitted nails-> psoriatic arthritis
• daycare worker or mother of small children->parvovirus B19, usually self-limited to 1-3 months
• 2nd and/or 3rd MCP and PIP joint arthritis->hemochromatosis
• raynaud phenomenon and sclerodctyly->polymyositis or dermatomyositis
• recent immunization->post-rubella immunization arthritis

Question 4

Extra-articular manifestations of RA

Answer 4

• c1-c2 subluxation->arm paresthesias and hyperreflxia
• BOOP->cough, fever, Pulm infiltrates
• foot drop or wrist drop->mononeuritis multiplex(vasculitis)
• hoarseness->cricoarytenoid involvement
• caplan syndrome->multiple basilar Pulm nodules
• sjogren syndrome->dry eyes, dry mouth
• rheumatoid pleuritis->pleural effusion with low blood glucose
• pulm fibrosis->rheumatoid interstitial lung disease
• rheumatoid vasculitis->skin ulcers, peripheral neuropathy
• felty syndrome->splenomegaly and granulocytopenia
• scleritis->red, painful eye
• HF->rheumatoid arthritis or anti-TNF therapy

Question 5

RA treatment

Answer 5

Quick symptomatic relief->NSAIDs and low dose oral and intra-articular steroids. These do not alter course of disease
Nonerosive disease(early, mild): monotherapy with hydroxychloroquine or sulfsalazine or combination therapy with these 2 meds
Erosive disease: methotrexate

Question 6

When to use biologics for RA treatment

Answer 6

• when disease is not adequately controlled, add TNF-alpha inhibitor to methotrexate
• screen for TB prior to starting
• treat for latent TB is positive before beginning biologics

Question 7

Common toxicities of TNF-alpha therapy

Answer 7

• pancytopenia
• positive ANA associated with lupus like syndromes
• demyelinating disorders