Rheumatoid Arthritis Flashcards
What are the two immunogenetic markers (major histocompatability comples types) commonly seen in patients with rheumatoid arthritis?
HLA-DR4 or HLA-DR1
What are the diseases where rheumatoid factor can be detected?
primary Sjӧgren syn, SLE, cryoglobulinemia, hepatitis C, and systemic vasculitis
What is the antibody present at the onset of rheumatoid arthritis?
Anti-cyclic citrullinated peptide antibodies (anti-CCP)
When anti-CCP Ab’s are in high titer, what is it indicative of in RA?
Progressive erosive disease
What joints are involved with RA?
metacarpophalangeal, proximal interphalangeal, wrist, and metatarsophalangeal joints
What are the clinical presentations of RA?
Patients describe deep aching and soreness in the involved joints, which are aggravated by use and can be present at rest.
Hallmarks of RA in joints: stiffness, heat redness, soft tissue swelling, pain, dysfunction
What are constitutional features of rheumatoid arthritis?
Fatigue, weight loss, muscle pain, excessive sweating, or low-grade fever may be reported by patients presenting w/ RA; most patients w/ active arthritis have more than 1 hr of morning stiffness
How can involvement of the cervical spine be used to Dx RA?
50% of all patients with chronic RA have radiographic involvement of the AA joint; this is diagnosed from cervical flexion and extension radiographs showing subluxation
What are the symptoms associated with cervical spine involvement in a patient with rheumatoid arthritis
pain and stiffness in the neck, drop attacks, hand weakness, interference with blood flow with the vertebral arteries causes the neurological Sx
What are the indications for surgical treatment in a patient with cervical spine rheumatoid arthritis?
neurologic or vascular compromise and intractable pain
What is the presentation of tenosynovitis?
diffuse swelling between the joints and a palpable grating within the flexor tendon sheaths in the palm with passive movement of the digit
What are the 1st and 2nd most common etiologies for carpal tunnel syndrome (CTS)?
Rheumatoid arthritis and inflammatory arthritis
What are the initial Sx of CTS?
Pts will present with paresthesias of the hand in a typical median nerve distribution with the discomfort radiating up the forearm or into the upper arm.
Symptoms worsen at night due to prolonged flexion of the wrist
What are the late Sx of CTS?
thenar muscle weakness and atrophy and permanent sensory loss.
What is the Tx of CTS?
resting splints, control of inflammation, and local injection of glucocorticosteriod
What is the clinical presentation of boutonniere deformity?
hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint
What is the clinical presentation of swan-neck deformity?
hyperextension at the proximal interphalangeal joint and flexion of the distal interphalangeal joint
What is the clinical presentation of ulnar deviation of the MP joints?
can progress to complete volar subluxtion of the proximal phalanx from the metacarpophalangeal head
Where might rheumatoid nodule be located?
over extensor surfaces and at pressure points; rare in the lungs, heart, sclera, and dura mater
How might rheumatoid nodules cause death?
Breakdown of the skin over rheumatoid nodules, with ulcers and infection, can be a major source of morbidity.
The infection can spread to local bursae, infect bone, or spread hematogenously to joints
who is at risk for rheumatoid vasculitis?
Rheumatoid vasculitis usually occurs in persons with severe, deforming arthritis and a high titer of rheumatoid factor
What happens in obliterative enarteropathy?
Proliferation of the vascular intima and media causes this obliterative endarteropathy, which has little associated inflammation
What happens in leukocytoclastic (small cell) vasculitis?
produces palpable purpura or cutaneous ulceration, particularly over the malleoli of the lower extremeties.
What shows with the the pleural fluid seen in rheumatoid pleural effusions?
The pleural fluid is an exudate with a concentration of glucose that is low (10-50 mg/dL) because of impaired transport of glucose into the pleural space.
What are the pulmonary nodules seen in rheumatoid arthritis?
Pulmonary nodules appear singly or in clusters; the single nodules have the appearance of a coin lesion.
Nodules typically are pleural-based and may cavitate and create a bronchopleural fistula.
What are the physical findings of interstital fibrosis?
diffuse dry crackles on lung auscultation and a reticular nodular radiographic pattern affecting both lung fields, initially in the lung bases.
What is the imaging modality used to differentiate between the interstitial rheumatoid lung syndromes?
high resolution CT
What might recurrent effusive pericarditis evolve into?
chronic constrictive pericarditis
What are the presenting manifestations of recurrent effusive pericarditis?
unexplained edema or ascites
What is the mortality and Tx of recurrent effusive pericarditis?
Untreated constrictive pericarditis has a very high 1-year mortality of 70%. It will not respond to medical therapies therefore surgical pericardiectomy is necessary.
Which lab abnormalities indicate liver impairment in rheumatoid arthritis?
increased levels of liver enzymes, particularly alkaline phosphatese, aspartate aminotransferase, γ- glutamyltransferase, and acute-phase proteins and hypoalbuminemia
What is the most common ophthalmic complication of rheumatoid arthritis?
Keratoconjunctivits sicca, or secondary Sjӧgren syndrome
What are the common lab abnormalities seen in rheumatoid arthritis patients?
, normocytic anemia (hemoglobin value about 10 g/dL), leukocytosis, thrombocytosis, hypoalbuminemia and hypergammaglobulinemia are common
What is the frequency of a positive rheumatoid factor and when its presence is detectable?
Rheumatoid factor (IgM) occurs in 90% of patients, but its presence may not be detected for months after the initial joint symptoms occur
What are the four diseases which are most likely to have a high-titer rheumatoid factor?
Rheumatoid arthritis, Sjӧgren syndrome, Mixed cryoglobulinemia, and subacute bacterial endocarditis
What is the antibody which is more specific for rheumatoid arthritis and may be present when rheumatoid factor is absent?
Anti-CCP antibodies
What is the presentation of the synovial fluid associated with rheumatoid arthritis?
is cloudy and light yellow, has poor viscosity, and typically contains 10,000 to 75,000 leukocytes/mcL, predominantly neutrophils
What are the radiographic findings in early RA?
radiographic findings are normal or show soft tissue swelling and periarticular osteopenia
What are the radiographic findings in later stage RA?
haracteristic changes of periarticular osteoporosis, symmetric narrowing of the joint space, and marginal bony erosions become obvious; most common in the hands and forefeet
What are the radiographic findings in end stage RA?
subluxtion and other deformities, joint destruction, fibrous ankylosis, and bony ankylosis.
What are the American Rheumatism Association criteria for diagnosing rheumatoid arthritis?
One or more hours of morning stiffness in and around the joints
Arthritis of 3 or more joint areas involved simultaneously
Arthritis of at least 1 area in the wrist, metacarpophalangeal or proximal interphalangeal joints
Symmetric arthritis involving the same joint areas on both sides of the body
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes typical of rheumatoid arthritis, including periarticular osteoporosis, joint-space narrowing, and marginal erosions.
Who are the patients that are at high risk of early disability from rheumatoid arthritis?
Patients who experience a persisting polyarthritis with increased acute-phase reactants and a positive rheumatoid factor or anti-CCP antibody are at high risk for early erosive disease within 1 to 2 years of symptom onset and early disability
What is the initial medication used in the treatment of rheumatoid arthritis?
NSAID
What is the role of disease-modifying agents of rheumatic disease (DMARDs) in the treatment of rheumatoid arthritis?
The goal of DMARD therapy is to slow disease progression (erosive damage) and maintain joint function
What are the ten DMARD agents?
Methotrexate, hydroxychloroquine, sulfasalazine, minocycline, leflunomide, cyclosporine, azathioprine, anti-cytokine therapies (including anti-tumor necrosis factor, IL-6 and IL-1 inhibitors), rituximab, and abatacept
When should DMARD therapy start?
Therapy with DMARD should be started early once RA is diagnosed
How long should DMARD therapy last?
Uninterrupted treatment with a disease-modifying agent for 3-6 months is usually to assess its effect. Combination DMARD therapy have come more common because it has shown enhanced benefits especially when it includes methotrexate.
What is the use of surgery in the treatment of rheumatoid arthritis?
Synovectomy of the wrist and nearby tendon sheaths is beneficial when medications are not working; this operation preserves joint function and prevents lysis of extensor tendons that can result in a loss of function.
What is the indication for arthroplasty in rheumatoid arthritis?
Arthroplasty is reserved for patients in whom medical management has failed and in whom intractable pain or compromise in function developed because of a destroyed joint. Joint replacement has had a major impact on reducing patient disability.
