Rheumatoid Arthritis

Question 1

RA Epidemiology

Answer 1

1% of pop
Females
Age

Question 2

RA Aetiology

Answer 2

Causes is unknown 
Association with some HLA variations 
Smoking
Chronic inflammatory response-> synovitis 
80% have positive RF IgG and IgM

Chronically inflammed synovium-> thickening
Osteoblast activation-> pannus formation
Articular cartilage erosion
Enthesis inflammation

Question 3

RA Symptoms

Answer 3

Joint pain and stiffness
Symmetrical
Small and medium joints
Early morning stiffness and after immobility 
Boggy swelling 
Responds to NSAIDS

Question 4

RA Signs

Answer 4

Swelling
Warmth
Joint line tenderness
Boutanniere and Swann neck
Ulnar deviation
Rheumatoid nodules-> firm, uniform, subcut-> areas of pressure or friction 
Tenosynovitis and bursitis

Question 5

RA Investigations

Answer 5

Bloods

• normochormic, normocytic anaemia
• increased ESR and CRP
• decreased albumin and increased ALP
• RF, 60% negative at presentation, more prognostic
• ACPA, more specific

X-ray

• hands, feet, chest
• peri articular ostopenia
• fluffy erosions
• soft tissue swelling
• narrowing of joint space

USS/MRI if early/undecided

Question 6

RA Medical Management

Answer 6

Treat early and aggressively
NSAIDS-> treat symptoms
Corticosteroids-> short course

Methotrexate

• oral or subcut
• weekly
• FBC, LFT, UE-> 2-3m
• > GI upset, oral ulcers, deranged LFT, pneumoconiosis, bone marrow suppression

Sulfasalazine

• daily
• FBC, LFT-> monthly
• > GI upset, rash/allergy, deranged LFT, bone marrow suppression

Combination-> methotrexate + X

• hydroxychloroquinine
• lefulomide

Biological

• anti TNF ‘mabs’
• anti B cell

Question 7

RA Non pharmacological managment

Answer 7

Physiotherapy
Occupational therapy
Education
Joint replacement

DAS 28 score -> monitor response

Question 8

RA The cervical spine

Answer 8

Atlanto-axial subluxation
Inflammation and erosive disease effecting the ligaments and vertebra
Neck pain that radiate to the occiput
May causes UMN lesion

• odontoid peg may slip upwards through the foremen magnum-> sudden death
• > take lateral flexion X Ray’s before anaesthetic

Question 9

RA Systemic symptoms

Answer 9

Wt loss
Fever
Malaise

Question 10

RA Cutaneous symptoms

Answer 10

Drug reactions
Vascultitis
Nodules
Leg ulcers-> Felty’s syndrome

Question 11

RA Neuro symptoms

Answer 11

Glove and stocking neuropathy
Carpal tunnel
Atlanto-axial subluxation
Mono neuritis multiplex

Question 12

RA Pulmonary symptoms

Answer 12

Pulmonary fibrosis

Nodules

Question 13

RA Caridovascular symptoms

Answer 13

Hypertension 
Atherosclerosis 
Pericarditis 
Myocarditis 
Coronary artetitis

Question 14

RA Eyes symptoms

Answer 14

Scleritis

Sjögren’s syndrome

Question 15

RA Amyloidosis symptoms

Answer 15

Production of amyloid in response to inflammation
Deposition in vessels and organs
-> failure
-> peripheral oedema
-> protienuria