Rheumatoid Arthritis Flashcards
autoimmune?
more common in?
seen in which age group?
commonly affects which joints?
strong RF for RA?
yes
females
all ages - most commonly 30-50
MCP, PIP joints (DIPS are rarely affected)
smoking
features?
deviation of fingers to which side?
Morning stiffness, improves with use
Bilateral symptoms
Systemic upset
ulnar deviation
how many are rheumatoid factor +ve?
how many are rheumatoid factor +ve after 10 yr progression?
difference in features?
40%
80%
Rhf +ve are more likely to have extra-articular manifestations
which gene makes you 60% more susceptible to RA?
HLA-DR4
which joints are usually affected?
- Stiff, swollen symmetrical distal joints in hand and feet – worse in morning and improves during the day.
- Boutonniere and swan neck deformities of digits are due to ?
PIP joint synovitis
why do you get radial deviation of wrist ?
to compensate for ulnar deviation of fingers.
- Only get rheumatoid nodules in ?
RhF +VE
Extra-articular features of RA
synovitis can cause median nerve compression - what condition is this?
often found in patients who test positive for rheumatoid factor. ?
– predom in seropositive for rheumatoid factor – features include leg ulcers and peripheral neuropathy?
Felty’s syndrome triad?
1/3 of RA patients will have?
bowel associations?
- Carpal tunnel syndrome – synovitis can cause median nerve compression – very common.
- Rheumatoid nodules in elbow, Achilles tendon and hand – often found in patients who test positive for rheumatoid factor.
Vasculitis
Triad of RA with splenomegaly and neutropenia.
– 1/3 of RA patients will have lung disease (fibrosis, nodules, effusion).
IBS associations
What are all raised in presence of synovitis?
increase in CRP, ESR, plasma viscosity (raised platelets)
which test is highly specific for RA (98% specificity)?
- Anti-CCP serological test – highly specific for RA (98% specificity).
- X-ray shows:
L
E
S
S
Loss of joint space narrowing
erosions
soft tissue swelling
soft bones (osteopenia)
what % of RA patients are ANA +ve?
30%
diagnosis of RA - how many out of 7 do you need for ARA criteria to be diagnosed ?
4 / 7
what is DAS28 score?
what score means:
- high disease activity?
- moderate disease activity?
- low disease activity?
a decrease in DAS28 score by what means a poor response to tx?
a decrease in DAS28 score by what means a good response to tx?
assess tenderness and swelling at 28 joints to calculate disease score
high = >5.1
moderate = 3.2-5.1
low <3.2
<0.6 = poor >1.2 = good
Tx of RA
conservative?
medical?
- Waiting to be referred from GP to rheumatologist?
- NICE recommend what within 3 months of first onset of symptoms as first line?
- what can you give alongside MTX?
- when do you administer biologics?
- what do you give for flares?
conservative
- exercise
- physiotherapy
- stop smoking
administer NSAID.
- NICE: 1st line within 3 months: combination of MTX + another DMARD + short term glucocorticoid
- folic acid to help with nausea
- failure of 2 DMARDs (using DAS28 score)
- Steroids rapidly reduce symptoms and inflame but have no effect on disease progresison – useful for when disease flares, administer methylprednisolone (intra-articular) or prednisolone (oral).
A 61-year-old female is reviewed in the rheumatology clinic with increasing shortness of breath. She has been on long-term drug therapy to control her rheumatoid arthritis. Her oxygen saturations on room air are on 89%. Investigations reveal the following:
Chest x-ray Bilateral interstitial shadowing
Which drug is most likely to be responsible for her symptoms?
infliximab
hydroxychloroquine
sulphasalazine
methotrexate
methotrexate
complications of drug therapy e.g. methotrexate pneumonitis
A 40-year-old woman is newly diagnosed with rheumatoid arthritis after a 6-month history of persistent wrist and hand pain. She also experiences stiffness each morning which takes 2 hours to fully resolve.
Her blood tests show a raised C-reactive protein and rheumatoid factor.
Which is of the following findings is most likely to be found on examination of the patient’s hands?
swollen DIP joints
swan neck deformity
boutonniere deformity
wrist tenderness
wrist tenderness
Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient
Whilst the swan-neck, boutonniere and Z-thumb deformities are all textbook hand findings of RA, they are secondary to joint and tendon changes caused by years of chronic synovitis and so would be unlikely in a newly diagnosed patient
A 45-year-old lady, with a past medical history of rheumatoid arthritis, is scheduled to have a laparoscopic cholecystectomy. What imaging should be performed pre-operatively?
anteroposterior and lateral cervical spine radiographs
CT cervical spine
hand radiographs
anteroposterior cervical spine radiographs
anteroposterior and lateral cervical spine radiographs
Atlantoaxial subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression. Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.
What is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression?
what is a preoperative screen?
Atlantoaxial subluxation
Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar
A 36-year-old female attends your GP clinic following her outpatient appointment with the rheumatologist. She has been informed of the complications of her rheumatoid arthritis, and is most concerned over the visual complications mentioned.
What can you inform her is the most common ophthalmic complication of her disease?
acute angle glaucoma
keratoconjunctivitis sicca
dry macular degeneration
anterior iritis
Most common eye complication of rheumatoid arthritis: keratoconjunctivitis sicca
Most common eye complication of rheumatoid arthritis?
keratoconjunctivitis sicca
An 82-year-old woman with long-standing rheumatoid arthritis presents with a history of recurrent chest infections over the past 6 months. On examination she is found to have splenomegaly. Her current medications include methotrexate and sulphasalazine.
What is the most likely cause of the neutropenia?
hodgkin's disease felty's syndrome non-hodgkin's disease CLL MTX use
felty’s syndrome
A 64-year-old female is referred to rheumatology out-patients by her GP with a history of arthritis in both hands. Which one of the following x-ray findings would most favour a diagnosis of rheumatoid arthritis over other possible causes?
loss of joint space
juxta-articular osteoporosis
subchondral cysts
subchondral sclerosis
juxta-articular osteoporosis
