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Rheumatology > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

What Is rheumatoid arthritis? (i.e the defintion of the disease)

A
  • Chronic auto immune systemic illness - Symmetrical destructive peripheral polyarthritis and other systemic features
  • Predisposition for the hands, particularly the IP, MCP and wrist joints, but can affect any synovial joint.
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2
Q

What is the general Prevalence of RA?

A

Prevalence - 1%

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3
Q

What is the pathogenesis and pathology of RA?

A
  • No clear antigen identified
  • Whatever the trigger ⇒ evidence of both innate and adaptive immune responses → Pro-inflammatory melieu dominated by cytokines such as TNF and IL-6.
  • Pathologically, the picture is of (see image)
  1. Inflammed synovial membrane
  2. Pannus formation - abnormal layer of fibrovascular tissue or granulation tissue. Pannus basically refers to the hypertrophied synovium
  3. Synovial fluid containing neutrophils (Major cell type - there are others!!)
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4
Q

What is the diagnostic classficiation system used for diagnosing RA?

A

American college of Rheumatology/European Union League Against Rheumatism classification criteria

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7
Q

What is the typical presentation of RA?

A
  • Progressive, symmetrical peripheral polyarthritis of hands and feet
  • Worse in the morning
  • Eased by movement
  • Can fluctuate
  • Can have extra-articular signs
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8
Q

What are the late SIGNS of RA?

A
  • Ulnar deviation
  • Dorsal Wrist Subluxation
  • Bouttonieres
  • Swan neck deformities
  • Z-deformity of the thumb
  • Ruptured hand extensor tendons
  • Large joints
  • Wasting of interossei
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9
Q

Think basic…

What are the general SYMPTOMS of RA?

A
  • Pain
  • Stiffness
  • Immobility
  • Poor function
  • Systemic Symptoms
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10
Q

What are the early SIGNS of RA?

A
  • Swelling
  • Joint effusions
  • Tenderness
  • Limitation of Movement
  • (Redness)
  • (Heat)
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12
Q

What are the non-specific extra-articular Signs/Symptoms?

A
  • Fatigue
  • Weight loss
  • Anaemia
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13
Q

How is disease activity assessed?

(Specifically describe the scoring system and the cut-offs for differing levels of disease activity)

A

DAS 28 Score

  • “An objective method for measuring disease activity”
  • >5.1 = Active disease
  • <3.2 = low disease activity
  • <2.6 = Remission

PLUS - CRP/ESR + Global Health assessment

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14
Q

What are the Eye symptoms that can be seen in RA?

A
  • Sicca syndrome
  • Scleritis/episcleritis
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15
Q

What other possible diagnoses could there be for a presentation similar to RA? (i.e. differential diagnosis?)

A
  • Post-viral arthritis: rubella, hepatitis B or erythrovirus
  • Seronegative spondyloarthropathies
  • Polymyalgia rheumatica
  • Acute nodal osteoarthritis (PIPs and DIPs involved)
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16
Q

What investigations would you perform to diagnose RA?

A
  • FBC, ESR, CRP
  • RF
  • Anti CCP, ACPA
  • Joint aspiration - If effusion is present
  • X-rays
  • US/MRI
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18
Q

How is RA managed?

A

Analgesia

  • NSAIDS

DMARDS - 1st line; should ideally be started within 3 months of persistent symtpoms. Can take 6-12 weeks for symptomatic benefit. Examples include:

  • Methotrexate
  • Sulfasalazine

Biologics - Idicated in active disease defined by DAS > 5.1. Adequate therapeutic trial of at least 2 standard DMARDs (including methotrexate) without improvement.

  • Anti-TNF - Entaracept, Infliximab, Adalimumab
  • IL-1, IL-6 - Tocilizumab
  • B-cells - Rituximab
  • T-cells - Abatacept

Steroids - used in acute flares to rapidly reduce symptoms and inflammation

Physio and OT input

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19
Q

What are poor prognostic markers of RA?

A
  • Age
  • Female sex
  • Symmetrical small joint involvement
  • Morning stiffness >30 min
  • >4 swollen joints
  • CRP >20
  • Positive RF and ACPA
  • X-rays with early erosive damage (note: ultrasound and MRI can show cartilage and bone damage prior to conventional X-rays).
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20
Q

Which gender does RA more commonly affect?

A

Females>Males - 3:1

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21
Q

When is the peak age of onset?

A

Peak age - 4th-5th decade

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22
Q

What is the cause of RA?

A

Unknown

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23
Q

What risk factors are associated with the development of RA

A
  • HLA DR4/DR1
  • Cigarette smoking
  • Chronic Infection (e.g. periodontal disease)
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24
Q

What is Rheumatoid Factor?

A
  • Circulating autoantibodies - Fc portion of IgG as their antigen
  • Transient production an essential part of the body’s normal mechanism for removing immune complexes
  • In RA, RF shows higher affinity for immune complexes, production is persistent and it occurs in the joints
  • Approx. 70% of people with polyarticular RA have serum IgM RF
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25
Q

What are Anti-cyclic citrullinated antibodies (Anti-CCP, ACPA)?

A
  • Citrullination - post-translation modification of the amino acid arginine to citrulline in a protein ⇒ changes both peptide sequence and charge ⇒ can escape conventional tolerance mechanisms.
  • Bacterial citrullination of self proteins in inflammation can also cause the same effect
  • ACPA present in RA along with RF - Highly specific for RA together
26
Q

Which joints are most commonly affected in RA?

A
  • MCP
  • PIP
  • DIP
  • Wrist
  • MTP
27
Q

Is the arthritis seen in RA symmetrical or asymmetrical?

A

Symmetrical

28
Q

What are the different components to the diagnostic classification system for RA?

A
  • Joint involvement
  • Serology
  • Acute phase reactants
  • Duration of symptoms
29
Q

What are the respiratory symptoms seen in those with RA?

A
  • Rheumatoid nodules
  • Pleural effusions
  • Fibrosing alveolitis
  • Pneumoconiosis (Caplans syndrome)
30
Q

What are the following?

A

Rheumatoid nodules - image represents common sites for them to develop

31
Q

What deformity is the following?

A

Ulnar deviation

32
Q

What deformity is this?

A

Boutonniere deformity

33
Q

What is this deformity?

A

Swan Neck Deformity

34
Q

What deformity is this?

A

Dorsal wrist subluxation

35
Q

What deformity is this?

A

Z-Deformity of the thumb

36
Q

The following scans were taken from someone with RA. What do they show?

A

Pulmonary Rheumatoid nodules

37
Q

What are features seen in the nervous system of those with RA?

A
  • Carpal tunnel syndrome
  • Peripheral Neuropathy
38
Q

What are the features on the skin seen in RA?

A

Rheumatoid nodules - particularly elbows

39
Q

What features on an X-ray would indicate RA?

A
  • Soft tissue swelling
  • Juxta-articular osteopenia
  • Decreased joint space
  • Bony erosions
  • Subluxation
  • Complete carpal destruction
41
Q

What score on the EULAR/ACR classification criteria is regarded as being diagnostic for RA?

A

Scores >/= 6/10

49
Q

What is Caplan’s syndrome?

A

Combination of RA and pneumoconiosis (occupational lung disease and a restrictive lung disease caused by the inhalation of dust, often in mines and from agriculture)

Presentation - with cough and shortness of breath with RA features

50
Q

What is koebner phenomenon?

A

The appearance of skin lesions on lines of trauma. The Koebner phenomenon may result from either a linear exposure or irritation. This explains why rheumatoid nodules grow on the elbows etc.

51
Q

What is the anatomical abnormality that occurs in a boutonniere’s deformity?

A

Rupture of the central slip of the extensor mechanism of the finger - Buttonhole deformity

52
Q

What is the anatomical abnormality that occurs in swan neck deformity?

A

Rupture of the lateral slip of the extensor mechanism in the finger

53
Q

What are the main side effects to methotrexate use?

A
  • Pulmonary fibrosis
  • Liver toxicity
  • Bone marrow suppression
54
Q

What drugs are contraindicated in someone using methotrexate?

A
  • NSAIDS - excretion is inhibited by nsaids
  • Trimethoprim - another folate antagonist
55
Q

What class of drug is methotrexate?

A

Folate antagonist

56
Q

What is the action of sulfasalzine?

A

Inhibits production of TNF and sytokines

57
Q

What can be a cause of sudden death in Rheumatoid arthritis?

A

Atlanto-axial subluxation

58
Q

How does atlanto axial subluxation occur in rheumatoid arthritis?

A

Rheumatoid tenosynovitis weakens tendons around odontoid peg - the peg can sublux backwards and compress the spine. This can present in two ways:

  • Slow subluxation - spastic tetraparesis
  • Acute subluxation - Cardiac arrest due to vagus nerve compressing
59
Q

What is important to do pre-operatively in someone with rheumatoid arthritis?

A

Lateral upper cervical spine radiograph in gentle flexion - look for atlanto-axial subluxation

60
Q

How would you distinguish RA from PA clinically?

A

DIP joints often spared in RA, whereas PA is mainly DIP joints involved

61
Q

How would you distinguish RA from OA clinically?

A

OA does not involve the MCP, whereas RA does

62
Q

What is impoprtant for those on methotrexate to take?

A

Folic acid 5 mg

63
Q

How long are steroids given for in RA?

A

Until onset of DMARDS

Rheumatology (20 decks)

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