Rheumatoid Arthritis Flashcards
How common is Rheumatoid Arthritis?
3% women (30-50yrs)
-no gender difference post-menopause
1% men
What is the cause of RA?
Familial disease
-inheritance sporadic
How does RA classically present?
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
What are the rarer presentations of RA?
Palindromic (recurring mono/poly arthritis)
Persistent mono-arthritis
Systemic illness w/ extra articular sx
What is the differential diagnosis for RA?
Reactive arthritis
Seronegative spondyloarthropathies
Polymyalgia rheumatica
Acute nodal osteoarthritis
What are the signs on examination of RA?
Warm/swollen/tender joints
Which joints are most commonly involved in RA?
Hands (spares DIPJs)
Feet
Large joints
What are the characteristic deformities present in RA affecting the hands?
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
What are common consequences of severe RA affecting the hands?
Ankylosis (fusion) across joint
Rupture of little/ring finger extensor tendons
-requires urgent surgical repair
Carpal Tunnel Syndrome
How does RA affecting the feet present?
MPTJ swelling
Foot becomes broader w/ hammer-toe deformity
Ulcers/callouses due to exposure of metatarsal heads
How does RA affecting the Large Joint present?
Affects knee>shoulder>hip
Genu valgus deformity
2o OA
What bloods should be done to diagnose/assess RA?
FBC CRP/ESR Rheumatoid Factor Anti-CCP ANA
What XR findings are suggestive of RA?
Soft tissue swellings around PIPJs/MCPJs -DIPJs spared Uniform joint space narrowing Juxta-articular osteopenia Periarticular erosions Subluxation/dislocation
What is the first change seen in the pathogenesis of RA?
Rheumatoid synovitis w/ swollen synovium
-villous pattern
-neutrophil infiltration
Leads to exudative effusion w/i joint (boggy/swollen)
How does the pathogenesis of RA progress?
Vascular granulation tissue (pannus) destroys articular cartilage
Pannus causes focal destruction of bone/destruction of whole cartilage
What is pannus?
Vascular granulation tissue formed by osteoclasts & macrophages
What causes morning stiffness in RA?
Cortisol trough OR
Build up of inflammatory mediators during non-activity
What are the features of/systems affected by extra-articular rheumatoid disease?
Rheumatoid nodules Vasculitis Pulmonary Cardiac Nervous Ocular Renal Haematological
How common are Rheumatoid Nodules?
Seen in 20% of RA pts
- associated w/ smoking
- seropositive disease only
What causes Rheumatoid Nodules?
Occur at sites of recurrent mechanical stress
- over bony prominences
- formed of necrotic inflam tissue
- can be underlying erosions
What are the Pulmonary Sequelae of extra-articular rheumatoid disease?
Pulmonary fibrosis -also caused by treatment w/ Methotrexate Pleural effusions -exudative Intrapulmonary rheumatic nodules -mainly asymptomatic
What Vasculitis occurs in extra-articular rheumatoid disease?
Nail-fold infarcts (cutaneous vasculitis)
Skin necrosis
Bowel infarction (mesenteric vasculitis)
What are the Cardiac Sequelae of extra-articular rheumatoid disease?
Pericardial involvement (30-40%)
-usually subclinical
-effusions can occur
Higher rates of MI/stroke
What are the Nervous Sequelae of extra-articular rheumatoid disease?
Entrapment neuropathies
Glove & stocking sensory loss (vasculitis of vasa nervorium)
What are the Ocular Sequelae of extra-articular rheumatoid disease?
Keratoconjunctivitis sicca (dry eyes)
-in association w/ Sjogren’s syndrome
Scleritis/episcleritis
-in severe seropositive disease
What are the Renal Sequelae of extra-articular rheumatoid disease?
Nephrotic syndrome/renal failure (due to amyloidosis)
What are the Haematological Sequelae of extra-articular rheumatoid disease?
Felty’s syndrome
Normocytic normochromic anaemia
What is Felty’s syndrome?
Splenomegaly + anaemia + neutropenia associated w/ RA
How common is atlantoaxial instability in RA?
50-80% of pts w/ RA of cervical spine
How does atlantoaxial instability present?
Localised pain & deformity
Cervical radiculopathy
What investigations are needed to diagnose atlantoaxial instability?
XR (APO, lat & odontoid peg)
MRI (cervical spine)
What is the management of atlantoaxial instability?
Surgical decompression of spinal cord
Stabilisation of involved segment
What is the medical management of RA?
Combination DMARD
- 1st line = Methotrexate + hydroxychloroquine
- short term glucocorticoids (IM methylpred)
- NSAIDs (relieves night pain/morning stiffness)
What lifestyle measures should be initiated in RA?
Stopping smoking
Hydrotherapy
When are biological agents indicated?
At least two DMARDs have been tried AND
Disease activity score (DAS) >5.5
What are the biological agents used to treat RA?
Infliximab
Etanercept
What is the disease activity score?
Scoring system based on
- number of swollen sites
- number of tender sites
- CRP/ESR
- pt perception of disease activity
What is the surgical management of RA?
Synovectomy (monoarticular disease) Excision arthroplasty (of ulnar styloid/metatarsal heads) Total joint replacement
