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CP3 @ UoN - Musculoskeletal & MDD > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

How common is Rheumatoid Arthritis?

A

3% women (30-50yrs)
-no gender difference post-menopause
1% men

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2
Q

What is the cause of RA?

A

Familial disease

-inheritance sporadic

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3
Q

How does RA classically present?

A

Symmetrical polyarthritis
Red, warm, painful/swollen peripheral joints (hands/feet)
-progresses to larger joints
-worse in morning
-evolves over weeks to months (70%) OR
-rapid onset of sx over days/overnight (15%)
Malaise/wt loss/disturbed sleep
Extra-articular features

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4
Q

What are the rarer presentations of RA?

A

Palindromic (recurring mono/poly arthritis)
Persistent mono-arthritis
Systemic illness w/ extra articular sx

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5
Q

What is the differential diagnosis for RA?

A

Reactive arthritis
Seronegative spondyloarthropathies
Polymyalgia rheumatica
Acute nodal osteoarthritis

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6
Q

What are the signs on examination of RA?

A

Warm/swollen/tender joints

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7
Q

Which joints are most commonly involved in RA?

A

Hands (spares DIPJs)
Feet
Large joints

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8
Q

What are the characteristic deformities present in RA affecting the hands?

A

Ulnar deviation at MCPJs
Radial deviation at wrist
Boutonniere deformity (hyperflexed PIPJs, hyperextended DIPJs)
Swan-neck deformity (hyperflexed DIPJs, hyperextended PIPJs)
Z-deformity in thumb (flexed MCPJs, extended IPJs)
Volar subluxation at MCPJs

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9
Q

What are common consequences of severe RA affecting the hands?

A

Ankylosis (fusion) across joint
Rupture of little/ring finger extensor tendons
-requires urgent surgical repair
Carpal Tunnel Syndrome

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10
Q

How does RA affecting the feet present?

A

MPTJ swelling
Foot becomes broader w/ hammer-toe deformity
Ulcers/callouses due to exposure of metatarsal heads

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11
Q

How does RA affecting the Large Joint present?

A

Affects knee>shoulder>hip
Genu valgus deformity
2o OA

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12
Q

What bloods should be done to diagnose/assess RA?

A 
FBC
CRP/ESR
Rheumatoid Factor
Anti-CCP
ANA
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13
Q

What XR findings are suggestive of RA?

A 
Soft tissue swellings around PIPJs/MCPJs
   -DIPJs spared
Uniform joint space narrowing
Juxta-articular osteopenia
Periarticular erosions
Subluxation/dislocation
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14
Q

What is the first change seen in the pathogenesis of RA?

A

Rheumatoid synovitis w/ swollen synovium
-villous pattern
-neutrophil infiltration
Leads to exudative effusion w/i joint (boggy/swollen)

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15
Q

How does the pathogenesis of RA progress?

A

Vascular granulation tissue (pannus) destroys articular cartilage
Pannus causes focal destruction of bone/destruction of whole cartilage

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16
Q

What is pannus?

A

Vascular granulation tissue formed by osteoclasts & macrophages

17
Q

What causes morning stiffness in RA?

A

Cortisol trough OR

Build up of inflammatory mediators during non-activity

18
Q

What are the features of/systems affected by extra-articular rheumatoid disease?

A 
Rheumatoid nodules
Vasculitis
Pulmonary 
Cardiac 
Nervous 
Ocular 
Renal
Haematological
19
Q

How common are Rheumatoid Nodules?

A

Seen in 20% of RA pts

  • associated w/ smoking
  • seropositive disease only
20
Q

What causes Rheumatoid Nodules?

A

Occur at sites of recurrent mechanical stress

  • over bony prominences
  • formed of necrotic inflam tissue
  • can be underlying erosions
21
Q

What are the Pulmonary Sequelae of extra-articular rheumatoid disease?

A 
Pulmonary fibrosis
   -also caused by treatment w/ Methotrexate
Pleural effusions
   -exudative
Intrapulmonary rheumatic nodules
   -mainly asymptomatic
22
Q

What Vasculitis occurs in extra-articular rheumatoid disease?

A

Nail-fold infarcts (cutaneous vasculitis)
Skin necrosis
Bowel infarction (mesenteric vasculitis)

23
Q

What are the Cardiac Sequelae of extra-articular rheumatoid disease?

A

Pericardial involvement (30-40%)
-usually subclinical
-effusions can occur
Higher rates of MI/stroke

24
Q

What are the Nervous Sequelae of extra-articular rheumatoid disease?

A

Entrapment neuropathies

Glove & stocking sensory loss (vasculitis of vasa nervorium)

25
Q

What are the Ocular Sequelae of extra-articular rheumatoid disease?

A

Keratoconjunctivitis sicca (dry eyes)
-in association w/ Sjogren’s syndrome
Scleritis/episcleritis
-in severe seropositive disease

26
Q

What are the Renal Sequelae of extra-articular rheumatoid disease?

A

Nephrotic syndrome/renal failure (due to amyloidosis)

27
Q

What are the Haematological Sequelae of extra-articular rheumatoid disease?

A

Felty’s syndrome

Normocytic normochromic anaemia

28
Q

What is Felty’s syndrome?

A

Splenomegaly + anaemia + neutropenia associated w/ RA

29
Q

How common is atlantoaxial instability in RA?

A

50-80% of pts w/ RA of cervical spine

30
Q

How does atlantoaxial instability present?

A

Localised pain & deformity

Cervical radiculopathy

31
Q

What investigations are needed to diagnose atlantoaxial instability?

A

XR (APO, lat & odontoid peg)

MRI (cervical spine)

32
Q

What is the management of atlantoaxial instability?

A

Surgical decompression of spinal cord

Stabilisation of involved segment

33
Q

What is the medical management of RA?

A

Combination DMARD

  • 1st line = Methotrexate + hydroxychloroquine
  • short term glucocorticoids (IM methylpred)
  • NSAIDs (relieves night pain/morning stiffness)
34
Q

What lifestyle measures should be initiated in RA?

A

Stopping smoking

Hydrotherapy

35
Q

When are biological agents indicated?

A

At least two DMARDs have been tried AND

Disease activity score (DAS) >5.5

36
Q

What are the biological agents used to treat RA?

A

Infliximab

Etanercept

37
Q

What is the disease activity score?

A

Scoring system based on

  • number of swollen sites
  • number of tender sites
  • CRP/ESR
  • pt perception of disease activity
38
Q

What is the surgical management of RA?

A 
Synovectomy (monoarticular disease)
Excision arthroplasty (of ulnar styloid/metatarsal heads)
Total joint replacement

CP3 @ UoN - Musculoskeletal & MDD (26 decks)

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