Rheumatoid Arthritis Flashcards
A 37 y/o day care attendant is seen by a nurse practitioner after 4 weeks of polyarthritis of the wrists MCPs and knees. RA latex is positive. She is diagnosed with RA and started on low dose MTX. Which is true?
- A positive anti- CCP will confirm the diagnosis.
- X-ray or ultrasound may confirm the diagnosis.
- Treatment should always start with NSAIDs.
- CRP should be done before starting MTX.
- She probably has an alternative diagnosis.
She probably has an alternate Dx - parvovirus B19
What causes carpal tunnel?
“MEDIAN TRAP”
Myxedema
Edema
Diabetes
Infiltration (sarcoid, leukemia, fibrosis)
Amyloid
Neoplasms
Trauma
RA
Acromegaly
Pregnancy
What infections should be expected for a gardner with septic joint?
Sporotrichosis
Nocardiosis
Blastomycosis* - decomposed wood in north central or southern US
Pantoea (Enterobacter) agglomerans - Opportunistic infection from plants and animal feces.
What are the ocular manifestations of RA?
Scleritis and potential scleromalacia perforans as isolated complication of RA or part of the Sicca Syndrome with keratoconjunctivitis sicca.
Dry eye
Sicca syndrome includes dry mouth with potential caries, test with Shermer test
scleromalacia perforans is when eye is flat, humor has run out
What are the cervical manifestations of RA?
A-A Subluxation
Erosion of odontoid process
C-spine ankylosis
With subluxation, patients tend to have C2 radiculitis and myelopathic symptoms, including extremity weakness, gait and balance problems.
+ Romberg test, with numbness in extremities
Important to measure displacement and amt of cord compression
- anesthesia and hyperflexion of the neck indicates complete cord compression
What are the pulmonary manifestations of RA?
Cough
Dyspnea
“Cellophane crackles” – close to the ear crackles
Pulmonary fibrosis
Caplan’s syndrome (RA nodules in lungs)
What is Caplan’s syndrome?
rheumatoid pneumoconiosis, also known as Caplan’s syndrome, can occur in workers exposed to silica, as well as in patients with silicosis, coal workers’ pneumoconiosis or asbestosis.
It was originally described in coal workers with pneumoconiosis.
Where can rheumatoid nodules present? What do they mean, and are more likely to have?
Rheumatoid nodules
- in skin, sclera, lungs
Often mean RF seropositivity
- more likely to have vasculitis and anti-CCP Ab
In addition to rheumatoid nodules, what skin changes are often present in RA?
Neutrophilic dermatosis/Sweet’s Syndrome
(Type IV/IL-8 &GM-CSF neutrophilia, overproduction of IL-8 in Th1 pathway inducing neutrophilia)
Pyoderma gangrenosum (all WBCs infiltrating skin, part of RA but also seen in CML, Crohn’s, UC, IgA myeloma)
Livedo reticularis - rheumatoid med vessel vasculitis, also seen in polyarteritis nodosa of anti-phospholipid Ab syndrome)
Small vessel vasculitis - circular purpura, RA vasculitis is most often small vessel vasculitis
What will many people with RA have on abdominal exam?
Felty’s Syndrome, complication of long-standing RA
SANTA:
Splenomegaly
Anemia (pale, hypochromic red cells)
Neutropenia Nodules
Thrombocytopenia
Arthritis - RA
Explain the classification criteria for Dx of RA.
2010 Classification criteria for RA diagnosis:
6 out of 10 = RA
- Number and site of involved joints: 1-5 points
2 to 10 large joints = 1 point
1 to 3 small joints = 2 points
4-10 small joints = 3 points
> 10 joints (including at least one small joint) = 5 points
- Serological abnormality (RF or Anti-CCP): 2-3 points
Low positive (above the upper limit of normal, ULN) = 2 points
High positive (greater than 3 times the ULN) = 3 points
- Elevated acute phase response (ESR, C-RP): 1 point (above the ULN = 1 point)
- Symptom duration: 1 point
(at least six weeks = 1 point)
What are the newer biomarkers in RA?
14-3-3η (eta)
Multibiomarker Disease Acticity (MBDA)
What is 14-3-3η? What is the usefulness when Dx’ing RA?
14-3-3η involved in the regulation of protein phosphorylation and mitogen-activated protein kinase pathways. It can help to diagnose early RA when CRP is negative, most specific test.
What is the MBDA biomarker in RA Dx? What is it helpful with?
Multibiomarker Disease Acticity (MBDA). Includes IL-6, TNKr type 1, VCAM 1, EGF, VEGF-A, etc*.
ie.YKL-40, matrix metalloproteinase-1, MMP-3, CRP, SAA, leptin, resistin
High MBDA > 44 is associated with rapid radiologic progression, and response to TNFi ove triple therapy.
What are the rheumatic diseases with a positive RF?
Rheumatic diseases with positive (> 50%) RF:
Cryoglobulinemia*
Sjogrens
RA
MCTD
What are the non-rheumatic diseases with positve RF?
Non-rheumatic diseases with positive RF:
Infections – parasites, leprosy, SBE*, virus (Hep C)
Lung diseases – silicosis, IPF
Miscellaneous - PBC
*High titer RF without rheumatic disease, Subacute Bacterial Endocarditis
