RHEUMATOID ARTHRITIS

Question 1

Define rheumatoid arthritis.

Answer 1

It is an autoimmune chronic inflammatory disorder which often symmetrically affects the small and medium sized joints. It is characterized by an inflammation of the synovium which leads to damage of the articular cartilage.

Question 2

What is rheumatoid factor?

Answer 2

An auto-antibody

Question 3

What is rheumatoid factor an antibody to?

Answer 3

Rheumatoid factors are antibodies against the Fc portion of IgG.

Question 4

What isotype of immunoglobulin are rheumatoid factors?

Answer 4

Any. Typically IgM.

Question 5

Apart from rheumatoid arthritis, when might rheumatoid factor be detected in a patient’s blood? (Name at least 5)

Answer 5

Sjogren's syndrome
Felty's syndrome
Systemic sclerosis
Infective endocarditis
Systemic lupus erythematous
Infective mononucleosis (EBV)
Hepatitis
Tuberculosis
Dermatomoysitis
Syphillis
HIV
Influenza
Malignancy
Sarcoidosis
Leukaemia
Elderly

Question 6

Other than rheumatoid factor, what might you look for in the blood of a patient with suspected rheumatoid arthritis?

Answer 6

Anti-CCP

Question 7

What does anti-ccp stand for?

Answer 7

Anti-cyclic citrullinated peptide

Question 8

Apart from diagnosis, what might levels of RF (rheumatoid factor) and anti-CCP tell you?

Answer 8

Prognosis. A worse prognosis is associated with raised markers.

Question 9

What are the risk factors for rheumatoid arthritis? (Name 5)

Answer 9

Genetics
Smoking
Ebstein-Barr virus (EBV)
Human Herpes Virus 6 (HHV-6)
Vitamin D deficiency (could be more of a consequence than a cause)

Question 10

What is the peak age of onset for rheumatoid arthritis?

Answer 10

40-60

Question 11

What is the ratio of rheumatoid arthritis patients in terms of gender?

Answer 11

More than 2:1 women to men

Question 12

What are the articular symptoms that a patient with suspected rheumatoid arthritis might present with? (Name at least 4 symptoms)

Answer 12

Swollen joints
Painful joints
Stiff joints
Joints affected would be hands and feet mainly
Worse symptoms in the morning.
Can be quite sudden onset of symptoms.
Recurring soft tissue problems such as frozen shoulder.

Question 13

What are the extra-articular symptoms that a patient with suspected rheumatoid arthritis might present with? (Name 3)

Answer 13

Fatigue
Weight loss
Fever
Pleuritic chest pain
Mononeuritis multiplex (odd sensation in different fingers and toes)

Question 14

Who is more likely to experience the extra-articular symptoms?

Answer 14

Males

Question 15

What are the early articular signs that a patient with suspected rheumatoid arthritis might present with? (Name 3)

Answer 15

Inflammation of several joints: MCP, PIP, wrist, MTP.
Tenosynovitis
Bursitis

Question 16

What are the more advanced articular signs that a patient with suspected rheumatoid arthritis might present with? (Name at least 5)

Answer 16

Ulnar deviation of the fingers
Dorsal wrist subluxation
Boutonierre on the fingers
Swan neck deformities of the fingers
Z-deformity of the thumbs
Rupture of the hand extensor tendons
Raynaud's carpal tunnel syndrome
Similar changes in feet
Larger joints can be involved

Question 17

What are the more advanced extra-articular signs and complications that a patient with suspected rheumatoid arthritis might present with? (Name at least 5)

Answer 17

Nodules on the elbows
Nodules on the lungs
Lymphadenopathy
Vasculitis
Fibrosing alveolitis
Obliterative bronchiolitis
Pleural effusion
Pericardial effusion
Peripheral neuropathy
Splenomegaly
Scleritis
Episcleritis
Osteoporosis
Amyloidosis
Ischaemic heart disease
Stroke

Question 18

What is Felty’s syndrome?

Answer 18

Rheumatoid arthritis + splenomegaly + neutropenia

Question 19

What investigations would you order to explore your patient’s signs and symptoms and what might they show?

Answer 19

Blood tests looking for rheumatoid factor and Anti-CCP
FBC to look for anaemia of chronic disease
Increased platelet count (Thrombocytosis)
Raised ESR (erthrocyte sedimentation rate)
Raised CRP

X-rays show soft tissue swelling, juxta-articular osteopenia and reduced joint space. More advanced disease will show bone erosion, subluxation and complete carpal destruction.

Ultrasound, MRI or bone scans may identify synovitis and bone erosion better than x-ray.

Question 20

What are the pain relieving drugs used with rheumatoid arthritis patients? For each class give an example of a drug commonly used.

Answer 20

NSAIDs - ibuprofen
Paracetamol
Opiates - codeine, tramadol

Question 21

Are DIP joints often affected in rheumatoid arthritis?

Answer 21

No. This is more in osteoarthritis.

Question 22

What percentage of rheumatoid arthritis patients are seropositive for rheumatoid factor?

Answer 22

Only about 70%.

Question 23

What is the specificity of anti-ccp in rheumatoid arthritis patients?

Answer 23

Very high. About 98%.

Question 24

Apart from anti-CCP and RF, what other plasma autoantibodies might rheumatoid arthritis patients be seropositive for?

Answer 24

ANA (Antinuclear antibody)

ANCA (Antineutrophil cytoplasmic antibody)

Question 25

What is the DAS28 and what is it used for?

Answer 25

The 28 joint Disease Activity Score is used to assess disease activity. It assesses tenderness and swelling at 28 joints including the MCPs, PIPs, wrists, elbows, shoulders and knees, as well as taking into account the patient’s ESR and their self-reported symptom severity.

Question 26

Beyond pain relief, what medication might be given to someone recently diagnosed with rheumatoid arthritis?

Answer 26

DMARDs (Disease modifying anti-rheumatoid drugs) - such as methotrexate, leflunomide, hydroxychloroquine and sulfasalazine.

Steroids - IM methylprednisolone, oral prednisolone or intra-articular steroid injections.

Biological agents - TNF alpha inhibitors, B cell depletors, inhibitors of IL-1 and IL-6, disruptors of T cell function.

Question 27

What is a major cause of the reduced life expectancy of patients with RA?

Answer 27

Increased atherosclerosis

Question 28

What are the major cell types involved in the inflammation of the synovial in RA?

Answer 28

T-lymphocytes
Macrophage like (type A) synoviocytes
Fibroblastic (type B) synoviocytes

Question 29

What can we say about prognosis of those RA patients without positive autoantibodies vs those with?

Answer 29

The prognosis of those who present as sero-negative is better.

Question 30

What is the gene involved in rheumatoid arthritis?

Answer 30

HLA-DR4