Rheumatoid Arthritis

Question 1

What is arthritis?

Answer 1

a chronic systemic inflammatory disease, characterised by symmetrical, deforming, peripheral polyarthritis

Question 2

What is the epidemiology of RA?

Answer 2

most common rheumatological disease - prevalence 1%

more commonly affects women in middle age

Question 3

What are the articular symptoms in early RA?

Answer 3

• Symmetrical severe joint pain, stiffness (worst in the morning) and swelling
• Insidious onset of polyarthritis
• Inflammation in the joint (pain, swelling, heat, loss of function and erythema)

Question 4

What articular signs can be seen in early RA?

Answer 4

Severe inflammation around joint but no joint damage yet
Tenderness on squeezing joint
Pain on passive and active movements
Often have tenosynovitis or bursitis

Question 5

What are the systemic S&S in early RA?

Answer 5

weight loss
weakness
loss of appetite
rarely may have mild fever in acute attack

Question 6

What are the articular S&S seen in late RA?

Answer 6

joint damage occurring
remission is usually temporary but occasionally disease can burn out
deformities are permanent and secondary osteoarthritic changes are common

Question 7

Which joints are most commonly affected in RA?

Answer 7

V common = PIP, MCP, small joints of the feet - MTP and ankles
Common = Wrist, elbow, shoulder, knees

Question 8

How are the hands/wrists affected in early RA?

Answer 8

fingers are swollen, painful and stiff

inflamed flexor tendon sheaths increase functional impairment and may cause carpal tunnel syndrome

Question 9

What are the later changes seen in the hands of patients with RA?

Answer 9

ulnar drift and palmar (volar) subluxation of the MCPs 
fixed flexion (boutonniere deformity) or fixed hyperextension (swan-neck deformity) of PIP joints 
swelling and dorsal subluxation of the ulnar styloid (may cause rupture of the extensor tendons)

Question 10

What RA changes are seen in the shoulder?

Answer 10

early Sx may mimic rotator cuff tendinosis with a painful arc syndrome and pain in the upper arms at night
global stiffening gradually occurs and rotator cuff tears are common later in the disease

Question 11

What are the RA changes seen in the elbow?

Answer 11

synovitis of the elbow causes swelling, pain and fixed flexion deformity

Question 12

What RA changes are seen in the feet in RA patients?

Answer 12

• painful swelling of MTP joints is seen in early disease
• foot becomes broader and hammer toe deformity develops
• metatarsal heads are exposed and may lead to ulcers and calluses
• flat medial arch and loss of flexibility of the foot
• vagus position ankle
• walking becomes painful and limited

Question 13

How are knees/hips affected in RA?

Answer 13

Knees are more commonly effected and effusions and synovitis may occur
Secondary OA can follow in both the knee and hip
Total joint replacement may be necessary

Question 14

Which investigations are necessary to establish baseline for ongoing treatment in RA?

Answer 14

FBC, ESR, U&Es, LFTs, Calcium, TFTs, CRP, CXR

Question 15

Which investigations are diagnostic in RA?

Answer 15

RF, Anti-CCP, ACPA, ANA, X-ray of the hand and foot, joint ultrasounds (look for effusions, synovitis and erosions)

Question 16

What are the four main radiological changes seen in an X-ray of RA?

Answer 16

soft tissue swelling
periarticular osteoporosis (due to pain and secondary effects of steroids)
juxta-articular erosions (synovitis erodes bone and forms cysts)
narrowing of joint space
joint subluxation and malalignment

Question 17

What diagnostic criteria is often used in clinical practice?

Answer 17

• two or more swollen joints including at least one small joint
• morning stiffness lasting more than one hour for at least 6 weeks
• the detection of rheumatoid factors o autoantibodies into-CCP

Question 18

What is the DAS28 score?

Answer 18

it is used to monitor disease progression

• evaluates joints for swelling and pain
• visual analogue scale for how disease is affecting activity
• ESR/CRP is measures
• aim is to optimise treatment

Question 19

Describe the pathology of RA?

long

Answer 19

The main pathological abnormality is widespread persistent synovitis. Inflammatory cells infiltrate the synovium and it proliferates. Chronically inflamed tissue extends the joint margins and erodes the articular cartilage. Erosion of the cartilage and bone and ligament involvement leads to joint deformity.

Question 20

How common are rheumatoid nodules?

Answer 20

found in 20% of RA patients
usually accompany severe disease
possibly due to small vessel vasculitis

Question 21

What are the clinical features relating to extra-articular rheumatoid disease?

Answer 21

vasculitis 
sjogre's syndrome 
scleritis 
nodulosis 
fibrosing alveolitis 
pericarditis 
peripheral neuropathy 
entrapment neuropathy 
amyloidosis

Question 22

Where are rheumatoid nodules found in patients?

What is a complication of rheumatoid nodules?

Answer 22

rheumatoid noodles are seen in areas affected by pressure or friction such as the fingers, achilles and elbows
they are seen in patients who test positive for rheumatoid factor
nodulosis can occur and be complicated by infection

Question 23

What are the other soft tissue changes seen around joints?

Answer 23

bursitis at olecranon
tenosynovitis of flexor tendons in the hands causing stiffness
swelling of the extensor tendon sheath over the dorsal of the wrist is common
muscle wasting around the joint is common
osteoporosis can occur

Question 24

How are the lungs affected in RA?

Answer 24

Pleural effusion can occur early in the disease
Lung nodules can be found in seropositive patients (mostly asymptomatic)
Pneumonitis can lead to pulmonary fibrosis

Fibrosing alveolitis - combination of inflammation and basal lung fibrosis

Question 25

Why does vasculitis occur in RA?

Answer 25

caused by immune complex deposition in arterial walls
uncommon
smoking is a RF

Question 26

How is the heart affected in RA?

Answer 26

pericardial inflammation is common in RA but is rarely symptomatic
myocarditis and coronary arteritis is rare

Question 27

How is the nervous system affected in RA?

Answer 27

• peripheral sensory neuropathies
• compression neuropathies (carpal or tarsal tunnel syndrome due to synovitis)
• cord compression (due to atlantoaxial sublimation)

Question 28

How are the eyes affected in RA?

Answer 28

• scleritis and episcleritis can occur resulting in a painful red eye
• sick syndrome causes dry mouth and eyes

Question 29

How are the kidneys affected in RA?

Answer 29

Amyloidosis develops as a result of chronic inflammation. It causes proteinuria, nephrotic syndrome and CKD. Prognosis is poor.

Question 30

What are the causes of anaemia in RA?

Answer 30

anaemia of chronic disease
autoimmune haemolytic
felty’s syndrome
drugs used in RA can also cause this (NSAIDs, DMARDs)