Rheumatoid Arthritis

Question 1

Rheumatoid Arthritis (definition)

Answer 1

systemic autoimmune disease that primarily affects connective tissue, especially synovial joints.
-Actually destroys joints, as opposed to SLE, where joint damage is repairable

Question 2

RA Epidemiology (4 factors)

Answer 2

1. Sightly more common in women and Caucasians
2. Peak incidence is between age 40 and 60
3. Incidence increases with age
4. One of the most debilitating forms of arthritis

Question 3

RA Etiology (3 factors)

Answer 3

1. Genetics-runs in families, twin concordance, HLA genes of the MHC
2. Hormones-symptoms regress during pregnancy, estrogen promotes inflammation
3. Environment-exposure to unidentified antigen, EBV infection

Question 4

RA pathophysiology (type III)

Answer 4

Type III Pahto: Activated B cells synthesize RF (rheumatoid factors; antibodies)

• IgM and IgG against immunoglobulin fragments
• Immune complex formation in the joints and accumulation

Question 5

RA pathophysiology (type IV)

Answer 5

Type IV Patho: Activated T cells infiltrate joints

• CD4+ T cells, primarily Th1 (t helper cells)
• Become hyper activated and release of cytokines (IFN-g, IL-17)
• Inflammation in the joint (more recruitment of inflammatory factors) and autoamplification

Question 6

Tissue injury in RA (synovial joints)

Answer 6

1. Inflammation-irreversible tissue injury
   - Erosion of bone and cartilage in the joint space (from release of cytokines)
   - Reactive hyperplasia (when bone erodes, the body responds to increase growth of cells in the area, forming scar tissue)
   - reduced blood flow
   - Pannus formation (reduced motion, bony fusion, ankylosis)
2. Joint deformity
3. Mild vasculitis: skin, heart, CNS, lungs, GI

Question 7

RA clinical presentation I

Answer 7

1. Initial joint stiffness
   - Prominent in the morning (>30 min)
   - Subsides during the day
2. Joint pain
3. smaller joints affected at first

Question 8

RA clinical presentation II

Answer 8

1. Symmetrical joint involvement (see slide for reference)

Question 9

RA clinical presentation III (deformities and other signs)

Answer 9

1. Joint deformities
   - Ulnar deviation
   - Swan neck deformity
2. Other signs:
   - Palmar erythema (red palms)
   - Subcutaneous nodules
   - Systemic inflammation
   - Also muscle sches, not feeling well

Question 10

RA patient assessment (3 factors)

Answer 10

1. Blood testing
   - ACPA antibody tests (95% specific)
   - RF test (90% specific)
   - High IgG/IgM, ESR
2. Knee joint fluid evaluation
3. Joint x-ray (could see bone erosion and joint deformation)

Question 11

RA prognosis: Complication

Answer 11

Complications:

• Because of the lack of usage of the joint: muscle atrophy, carpal tunnel, retinal detachment, aortitis, cyst formation
• Most common causes of death are primarily due to complications of therapy

Question 12

RA prognosis: Patient Monitoring

Answer 12

~75% experience remission within 2 years

-Poor prognosis if >3 months, lack of therapeutic response, involvement of large joints (the knees or the hips)