Rheumatoid arthritis Flashcards
characterised by what
rheumatoid nodules (pathognomonic of RA
histopathology of rheumatoid nodules
Centre = fibrinoid necrosis
Then a circle of cellular palisade (densely packed layer of macrophages and fibrobasts)
Then layer of T cells and plasma cells
Outside -> Fibrous shell
describe inflammatory pain (this applies to RA, ank spond and any other joint inflammation…)
eases with use
early morning stiffness >60 mins
stiff at rest
what joints are never affected?
DIPs
in what diseases is there is there involvement of the DIPs
psoriatic arthritis
osteoarthritis
gout
what gene is associated with RA
HLA-DR4
HLA-DRB1
2 major pathological changes in joint RA
chronic synovitis
progressive erosion of articular cartilage
are joint effusions a transudate or exudate
exudate (NB exudates occur in inflammation whereas transudates occur due to increased hydrostatic pressure or low plasma oncotic pressure)
what bone erosion is seen in RA
periarticular
antibodies in RA
anti citrullinated cyclic peptide abs
rheumatoid facotr
onset
slowly progressive
is there joint swelling in RA
yes there may be
what joints are usually affected
small joints of hand and feet
can be cervical spine
polyarthropathy
5 hand signs
- Ulnar deviation
- Boutonniere deformity (flexion of PIP, extension of DIP)
- Swan neck deformity (hyperextension of PIP, flexion of DIP)
- Z-thumb (hyperextension of interphalangeal joint, fixed flexion and subluxation of MCP joint)
- Palmer MCP subluxation (MCP dislocates so that back of hand is higher than fingers)
toe defomitiy
hammer toe (fixed flexion of both joints of toe)
non-articular manifestation of RA
CARPALS carpal tunnel anaemia of chronic dis (normocytic normochromic) raynaud's pleural effusions and pericarditis amyloidosis (renal) lack of saliva (sjogren's) scleritis + episcleritis, splenomegaly
increased risk of IHD (causes death in most)
where do rheumatoid nodules occur
pressure points elbows finger joints achilles tendon can occur in lungs
specific Ix
rheumatoid factor
anti-CCP
hand feet xray
non specific ix
ESR, CRP - raised
FBC - normochromic normocytic anaemia
LFTs: mild elevation of alk phs and ggt
ANA - positive in SLE and 30% RA
referral time fram2
2ww
score to measure disease activity
DAS28
drugs for RA
para and codeine NSAIDs (+PPI) short term oral steroids steroid injection (intraarticular or IM as acute rx) DMARDs biologics
examples of DMARDs
methotrexate
ciclosporin
sulfasalzine
hydroxychloroquine
what combo of drugs to go for
methotrexate + another DMARD plus short term pred
what are the biologics?
multiple types (acting on different receptors). Some are anti-TNFs
abatacept
rituximab
tocilizumab
ANTI-TNFs adalimumab etanercept golimumab infliximab
what could a hot swollen joint mean
RA - sometimes the joints do become inflamed
septic arthritis - RA joints are at greater risk
when may pt with RA need surgery
persistent pain worsening joint function progressive deformity tendon rupture never entrapment
how do many people with RA die
CVS disease (RA increases risk)
findings on xray
LESS Loss of joint space Erosions (of bone) Soft tissue swelling Soft bone (periarticular osteopenia)
onset
4th and 5th decades
what do rheumatoid nodules feel like
mobile!
range between texture of frozen pea to cooked pea.
SEs mehtotrexate
n+v mouth ulcers hair thinning TERATOGENIC folic acid reduces risk of all of these
