Rheumatoid arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

A chronic inflammatory polyarthropy which primarily affects the musculoskeletal system, causing joint stiffness, deformity and pain.

Question 2

Describe the pathophysiology of rheumatoid arthritis.

Answer 2

Synoviocyte hypertrophy (pannus) causes inflammation and angiogenesis within the joint space. Resulting cartilage loss causes focal bone erosion and narrowed joint space. Inflammatory cytokines such as interleukins cause articular and extra-articular symptoms.

Question 3

What is pannus and why does it form?

Answer 3

Pannus is hypertrophy of synoviocytes, which forms due to the autoimmune response to citrullinated peptides.

Question 4

Give 3 risk factors for rheumatoid arthritis.

Answer 4

Genetics - HLADR4
Smoking
Increasing age - usually onset at age 50-60
Female (autoimmune!)

Question 5

Give 3 diagnostic features of rheumatoid arthritis

Answer 5

Pain eases with use
There is ulnar deviation
Symmetrical joint involvement

Question 6

Give 3 symptoms of rheumatoid arthritis.

Answer 6

Swollen, painful small joints of hands and feet, fluctuating

Stiffness - morning lasting >1 hour

Question 7

Give 3 deformities seen in RA.

Answer 7

Ulnar deviation
Boutonniere deformity - extensor tendon splits
Swan-neck deformity
Z-thumb deformity

Question 8

Give 3 extra-articular effects of rheumatoid arthritis.

Answer 8

The interleukins are usually responsible:
Trigger hepcidin release -> decrease blood iron -> anaemia
Get into blood vessels causing vasculitis
Rheumatoid nodules in skin and lungs due to macrophages and lymphocytes surrounding a necrotic tissue core.

Question 9

Give 3 differences between OA and RA.

Answer 9

Joint involvement: symmetrical, wrists and feet in RA, asymmetrical, hip and knees in OA.
X Ray - RA has erosion, osteopenia and soft tissue swelling; while OA has osteophytes and subchondral cysts and sclerosis.
Bloods: RA has raised inflammatory markers, RF and anti-CCP.
Extra-articular manifestations: Present only in RA.
Management: OA responds well to steroids while RA does not.

Question 10

What would bloods show for RA?

Answer 10

Bloods - anaemia, raised ESR/CRP, RF, anti-CCP (more specific)

Question 11

What 4 things would an X ray show for RA?

Answer 11

X Ray: Loss of joint space, erosion, soft bones (osteopenia), soft tissue swelling.

Question 12

Describe the management of RA.

Answer 12

1. Ibuprofen, paracetamol

2. 2 disease-modifying anti rheumatic drugs (DMARDs): methotrexate + rituximab.

Question 13

What is the main complication of RA?

Answer 13

Cardiovascular disease - 2-3x risk. Manage risk factors.