Rheumatoid arthritis

Question 1

Characteristics of RA

Answer 1

PSSSS+SS

PS4+SS

Painful, Symmetrical, Swollen, Stiff, Small joints
plus
Systemic Symptoms

Question 2

Major autoantibodies of RA

Answer 2

Most patients will have RF, rheumatoid factor ~80%, and its titer correlates with disease prognosis but not with acute activity.
RF is sensitive but not specific

anti-Citrullinated-peptide antibodies are mostly unique to RA. 50% sensitive 90% specific.

Question 3

Other disorders that may have RF

Answer 3

Systemic lupus erythematosus (SLE),
scleroderma,
Sjögren’s syndrome,
vasculitis

Question 4

Blood labs in RA besides antibodies

Answer 4

Increased ESR, Increased CRP

Normocytic, Normochromic anemia,
anemia of chronic disease/inflammation

Question 5

Joint symptoms of RA

Answer 5

Bone erosion, especiialy at the peri-articular or juxta-articular space.

Pannus (granulation tissue, fibrotic/inflammatory tissue) formation within the synovial cavity

Synovial fluid is inflammed.

Soft tissue swelling around the joint

Subchondral cysts

Hands: Ulnar deviation, swan neck and boutonniere deformities

Cervical spine: Atlanto-Axial or SubAxial subluxation!! high potential for spine injury in RA patients with neck pain.

Question 6

Treatment of RA

Answer 6

Early diagnosis and initiation of DMARDs is essential, slows course and improves prognosis

DMARDs: triple therapy is first line: MSH, Methotrexate, Sulfasalazine, and Hydroxychloroquine

Alternative DMARD: Leflunomide

For exacerbations: Steroids, IM or oral Prednisolone.

NSAIDS can alleviate acute symptoms but do not affect progression

Biologicals, TNF-a, IL-1, IL-6 blockers are 2nd line if DMARDs are ineffective, but are absolute contra’d in HIV, HBV, HCB, or TB patients for possible reactivation

Question 7

Systemic symptoms of RA

Answer 7

• Lung interstitial fibrosis and eventual honeycombing.
• Restrictive COPD
• Pleuritis and pleural effusion are very common.
• Rhematoid nodules in the lung leading to abscesses or cavitation

Rheumatoid nodules in 25%, can for in any tissue
-Fibrinoid necrotic core, surrounded by palisading histiocytes/macrophages. Paslisading key histology

Pericarditis
R. Nodules in the heart leading to myocardial dysfunction or arrhythmia.

Anemia, Neutropenia, and Pslenomegaly
RA + Neutropenia + Splenomegaly = Felty syndrome

Constitutional symptoms:
Fatigue, Morning stiffness, Fever

AA amyloidosis and renal disease

Sjogren syndrome often co-presents

Carpal tunnel syndrome

Cervical subluxation

Question 8

Signs that indicate against RA diagnosis

Answer 8

Lack of Systemic symptoms

Asymmetrical joint involvement

Distal IP joint involvement.

Question 9

What is the scoring system used to calculate RA severity

Answer 9

DAS 28
Disease activity score, classifying the disease as mild/moderate/severely active state.

measuring and weighting the potential affected joints out of the 28 joints of the arms, as well as the shoulders and knees.
based on tenderness, swelling, and patient ESR and CRP values.

Question 10

What environmental factor increases the chance of developing RA?

Answer 10

Smoking