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Y2 LCRS Musc Fwong > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Define Rheumatoid Arthritis

A

Chronic autoimmune disease characterised by pain, stiffness and SYMMETIRCAL SYNOVITIS (inflammation of synovial membrane) of synovial (diarthrodial) joints

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2
Q

When is the stiffness in the joints particularly bad in CHRONIC rheumatoid arthritis and what can make it better?

A

In the morning

It gets better with exercise

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3
Q

What causes the Rheumatoid nodules?

A

Rheumatoid factor produces immune complexes that can go anywhere. Nodules=immune complexes surrounded by macrophages (see below)

Nodules are formed via a Central area of fibrinoid necrosis (a type of necrosis) surrounded by histiocytes (type of issue macrophage) and peripheral layer of connective tissue

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4
Q

What type of antibody is the rheumatoid factor?

A

IgM antibody that binds to the Fc portion of IgG

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5
Q

Is rheumatoid arthritis more common in males or females?

A

More common in females (3:1)

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6
Q

What is the important genetic component that predisposes toRheumatoid Arthritis?

A

The genetic component comes down to a specific set of amino acids within the beta chain of the DR molecule (amino acids 70-74 of the DR Beta1-chain)
This set of amino acids is conserved among all HLA subtypes that are associated with rheumatoid arthritis – it is called the shared epitope

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7
Q

What important environmental factor can affect the susceptibility and severity of Rheumatoid Arthritis?

A

Smoking

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8
Q

State some joints that are commonly affected in Rheumatoid Arthritis.

A 
Metacarpophalangeal joint (MCP) 
Proximal interphalangeal joint (PIP) 
Wrists 
Knees 
Ankles 
Metatarsophalangeal joint (MTP)
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9
Q

Name and describe two deformities that are indicative of Rheumatoid Arthritis when left untreated

A 
Swan-neck deformity  
 Hyperextension of PIP
 Hyperflexion of DIP
Boutonniere deformity (button-like) 
 Hyperflexion at PIP
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10
Q

What is the term given to fingers that are completely swollen, notjust around the joints?

A

Dactylitis – this can’t be explained by Rheumatoid Arthritis because it is not just the joints that are inflame

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11
Q

Describe the appearance of extensor tenosynovitis.

A

There will be swelling of the Tenosynovium(synovial sheath surrounding tendons of extensor muscles of hand)
around the extensor tendon.

When the fingers are extended, the swelling will move showing that the inflammation is around the tendon and not the joint

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12
Q

Other that joints and around tendons, where else can synovium become inflamed?

A

Bursae –> Bursitis

bursas are lined with synovial membrane

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13
Q

What are sub-cutaneous nodules?

A

Central area of fibrinoid necrosis surrounded by histiocytes and a peripheral layer of connective tissue

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14
Q

Why are rheumatoid nodules an important clinical finding?

A

Patients with rheumatoid nodules are always rheumatoid factor positive

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15
Q

Where are rheumatoid nodules commonly seen?

A

Along the ulnar border

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16
Q

What proportion of cases of Rheumatoid Arthritis is rheumatoid factor negative?

A

1/3

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17
Q

Name another autoantibody that is very specific for Rheumatoid Arthritis.

A

Anti-cyclic citrullinated peptide antibody

18
Q

Which enzymes are responsible for the citrullination of peptides?

A

Peptidyl arginine deaminases, PADs (deamination because you are removing an amine group when converting arginine to citrulline)

19
Q

Why do citrullinated peptide antigens develop in rheumatoid arthritis?

A

PADs are present in high concentrations in neutrophils and monocytes so there is increased citrullination of autologous peptides in inflamed synovium. ( more inflammation=more inflamamtory cells eg neutrophils= more PAD enzymes)

Citrulline binds much better than arginine to the shared epitope (specific peptide sequence that is conserved in all MHC molecules that are associated with Rheumatoid Arthritis)

So Anti-CCP antibodies are more likely to develop in individuals with citrullinated autoantigens and those that have the shared epitope

20
Q

State some common extra-articular manifestations of Rheumatoid Arthritis.

A

Fever, weight loss, malaise (feel ill) and lethargy (tired). These are driven by cytokines and hence anti cytokine therapies eg anti TNF will also make patients feel better

Subcutaneous nodules (rheumatoid nodules)

21
Q

State some rare extra-articular manifestations of Rheumatoid Arthritis.

A

Vasculitis
Episcleritis
Neuropathies
Amyloidosis
Lung disease (nodules, fibrosis, pleuritis)
Felty’s syndrome (triad of splenomegaly, leukopenia and rheumatoid arthritis)

22
Q

What is an early radiographic abnormality in Rheumatoid Arthritis?

A

Juxta-articular osteopenia (osteopenia is loss of bone minerals and protein but not as bad as osteoporosis ie BTEC osteoporosis)

23
Q

What are some later radiographic abnormalities in Rheumatoid Arthritis?

A

Joint erosion and, subsequently, joint destruction and deformity

24
Q

What is the name given to the thickened, chronically inflamed synovial tissue in Rheumatoid Arthritis?

A

Pannus

25
Q

Which area of bone tends to be eroded first in Rheumatoid Arthritis?

A

Bare area of bone – this is within the synovial membrane but is not covered by articular cartilage (periarticular erosion)

26
Q

How thick is the normal synovial membrane?

A

It is normally almost a single cell lining

27
Q

Which cells are responsible for producing synovial fluid?

A

Synovial fibroblasts

NOTE: macrophages are also found within the lining

28
Q

Why is synovial fluid viscous?

A

It contains hyaluronic acid

29
Q

What type of collagen is present in articular cartilage?

A

Type 2 collagen

30
Q

What is the main proteoglycan in articular cartilage?

A

Aggrecan

31
Q

What three main things are responsible for the synovium becoming a proliferated mass (pannus)?

A 
Neovascularisation  
Lymphangiogenesis 
Inflammatory cell recruitment: 
 Activated T and B cells 
 Plasma cells 
 Mast cells 
 Activated macrophages
32
Q

What are the three main cytokines involved in this disease process?

A

IL-1
IL-6
TNF-alpha

33
Q

What is the dominant cytokine and which cells produce it?

A

TNF-alpha

Produced by activated macrophages

34
Q

What is the main treatment goal for Rheumatoid Arthritis?

A

Prevent joint damage

35
Q

What class of drugs are commonly used in Rheumatoid Arthritis to modify the natural history of the disease?

A

Disease-modifying anti-rheumatic drugs (DMARDs)

36
Q

When are glucocorticoids used and why are they not used long term?

A

They are used in the short-term to control, for example, exacerbation of the disease
They are not used long-term because of their large side effect profile

37
Q

Describe the onset of action of DMARDs.

A

Slow onset and complex action

38
Q

Give some examples of DMARDs.

A

Methotrexate

Gold

39
Q

What are the shortcomings of DMARDs?

A

They have significant adverse effects and require regular blood test monitoring

40
Q

What are the major risks with biological therapy?

A

EXPENSIVE
All biological therapies are associated with an increase infection risk
TNF-alpha inhibition is associated with increased susceptibility to mycobacterial infections (TUBERCULOSIS)
So all patients must be screened for TB before starting treatment
B cell depletion is associated with HEPATITIS B activation so patients need to be screened for this as well
B cell depletion is also associated with JC virus infection and progressive multifocal leukoencephalopathy (PML) – RARE

Y2 LCRS Musc Fwong (11 decks)

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