Rheumatoid arthritis

Question 1

Define RA?

Answer 1

Chronic inflammatory autoimmune disease

Symmetrical, deforming, peripheral polyarthritis

Question 2

Risk factors of RA?

Answer 2

Smoking
Female

Certain HLA types: DR1 and DR4

Peak age of onset 50th and 60th decile

Question 3

Pathophysiology of RA?

Answer 3

Inflammation of synovial joints leading to joint and periarticular tissue destruction

Increased angiogenesis takes inflammatory cells to the area

They release cytokines (IL, TNF)

Hypertrophy of synovium and angiogenesis results in formation of pannus (granulation tissue) over articular cartilage

Question 4

Presentation of RA?

Answer 4

Symmetrical, swollen, erythematous, painful, stiff joints

Commonly hands and feet but later on larger joints can become affected

Pain worse in the morning, eases with movement

Progressive joint destruction, loss of function, deformity

Tendon rupture (as tendons have synovial linings)

Question 5

What are the signs of RA on examination?

Answer 5

Symmetrical, distal joint arthritis
Larger joints less effective

Hand deformities: swan neck, boutonniere’s, Z thumb, ulnar deviation

Muscle wasting and tendon rupture

Cervical complications

Question 6

What deformities can you see in the hands in RA?

Draw them

Answer 6

Swan neck
Boutoniere’s
Z thumb
Ulnar deviation

Question 7

There are some extra-articular manifestations of RA. What are they?

Answer 7

Eyes: keratoconjunctivitis sicca, scleritis

Skin: leg ulcers, rashes, nail fold infarcts

Nodules: appear in eyes, subcutaneous, lung, heart, vocal cords

Neuro: peripheral nerve entrapment, polyneuropathy, mononeuritis multiplex,

Atlanto-axial subluxation

Respiratory: pulmonary fibrosis, pleural effusion, obliterative bronchiolitis

Cardiovascular: atherosclerosis, pericardial effusion, vasculitis

Raynaud’s, carpal tunnel

Osteoporosis
Amyloidosis

Question 8

Investigations for RA?

Answer 8

Bloods: ESR, CRP, FBC (anaemia of chronic disease), LFTs

Synovial fluid analysis rules out gout

Rheumatoid factor: (positive in 60-70%)

Anti-CCP (more specific)

XR of hands and feet

Question 9

Which antibodies are tested for in RA?

Answer 9

Rheumatoid factor

Anti-cyclic citullinated peptide (CCP)

Question 10

What would you see on an XR in RA?

Answer 10

LESS

Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopenia)

Question 11

How is disease activity measured in RA patients?

What’s the aim?

Answer 11

Calculate score using DAS28
Based on number of tender and swollen joints, ESR and patient’s self assessment

Aim to get a score under 3

Question 12

Management of RA?

Answer 12

Physiotherapy, OT
Psychological services

NSAIDs

For new diagnosis, combo therapy with methotrexate + other DMARD + short term steroid

Steroids
- PO prednisolone
- IV methylpred
- intra-articular
Good to treat acute exacerbations

DMARDs:

• methotrexate
• sulfasalazine
• azathioprine

Biologics: second line
- anti-TNF (adalimumab, etanercept, infliximab

Question 13

What is Felty’s syndrome?

Answer 13

Triad!

RA
Neutropenia
Splenomegaly

Plus: leg ulcers, brown pigmentation, lymphadenopathy

Question 14

What can RA do to the lungs?

Answer 14

Interstitial lung disease

Rheumatoid nodules which can lead to pulmonary effusion

Caplan’s: nodules at lung peripheries

Methotrexate pneumonitis