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YR2: Musculoskeletal > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Define Rheumatoid Arthritis

A

Chronic AI disease characterised by pain, stiffness + SYMMETIRCAL SYNOVITIS of synovial (diarthrial) joints

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2
Q

What is a relatively common extra-articular manifestation of rheumatoid arthritis?

A

Rheumatoid nodules

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3
Q

What causes the extra-articular manifestations? What are 2 rarer extra-articular manifestations?

A

Rheumatoid factor produces immune complexes that can go anywhere
Vasculitis
Episcleritis

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4
Q

What type of antibody is the rheumatoid factor?

A

IgM autoantibody 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 to Rheumatoid Arthritis?

A

Specific set of AA’s (70-74) within the beta chain of the HLA-DR binding groove
This set of AA’s is conserved among all HLA subtypes that are associated with RA = 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 6 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.

A

Swan-neck deformity
Hyperextension of PIP + Hyperflexion of DIP
Boutonniere deformity (button-like)
Hyperflexion at PIP

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10
Q

Describe the appearance of extensor tenosynovitis.

A

Swelling around the extensor tendon that is inflamed

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

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11
Q

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

A

Bursae –> Bursitis

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12
Q

What are sub-cutaneous nodules?

A

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

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13
Q

Why are rheumatoid nodules an important clinical finding?

A

Patients with rheumatoid nodules are always rheumatoid factor positive

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14
Q

Where are rheumatoid nodules commonly seen?

A

Along the ulnar border of the forearm

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15
Q

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

A

1/3

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16
Q

Name another autoantibody that is very specific for Rheumatoid Arthritis.

A

Anti-cyclic citrullinated peptide antibody

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17
Q

Which enzymes are responsible for the citrullination of peptides?

A

Peptidyl arginine deaminases (PADs)

18
Q

Why do citrullinated peptide antigens develop in rheumatoid arthritis?

A

PADs are present in high concentrations in neutrophils + monocytes so there is increased citrullination of autologous peptides in inflamed synovium
Citrulline binds much better than arginine to the shared epitope
Anti-CCP antibodies are more likely to develop in individuals with citrullinated autoantigens (e.g. smokers)+ those that have the shared epitope

19
Q

State 3 common extra-articular manifestations of Rheumatoid Arthritis.

A

Subcutaneous nodules
Fever
Weight loss

20
Q

State 6 rare extra-articular manifestations of Rheumatoid Arthritis.

A

Vasculitis
Episcleritis (ocular inflammation)
Neuropathies
Amyloidosis
Lung disease (nodules, fibrosis, pleuritis)
Felty’s syndrome (triad of splenomegaly, leukopenia + RA)

21
Q

What is an early radiographic abnormality in Rheumatoid Arthritis?

A

Juxta-articular osteopenia

22
Q

What are some later radiographic abnormalities in Rheumatoid Arthritis?

A

Joint erosion at margins of joint

Subsequent joint destruction + deformity

23
Q

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

A

Pannus

24
Q

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

A

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

25
Q

How thick is the normal synovial membrane?

A

~ single cell lining

26
Q

Which cells are responsible for producing synovial fluid?

A 
Synovial fibroblasts (Synoviocytes)
Macrophage like cells are also found within the lining
27
Q

Why is synovial fluid viscous?

A

It contains hyaluronic acid

28
Q

What type of collagen is present in articular cartilage?

A

Type 2 collagen

29
Q

What is the main proteoglycan in articular cartilage?

A

Aggrecan

30
Q

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

A

Neovascularisation
Lymphangiogenesis
Inflammatory cell recruitment:
(Activated T + B cells, Plasma cells, Mast cells, Activated macrophages)

31
Q

What are the three main cytokines involved in Rheumatoid arthritis?

A

IL-1
IL-6
TNF-alpha

32
Q

What is the dominant cytokine and which cells produce it?

A

TNF-alpha

Produced by activated macrophages

33
Q

What is the main treatment goal for Rheumatoid Arthritis?

A

Prevent joint damage

34
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)

35
Q

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

A

Used in the short-term to control, e.g. control flare of disease
Not used long-term because of their large side effect profile

36
Q

Describe the onset of action of DMARDs.

A

Slow onset + complex action

37
Q

Give 3 examples of DMARDs.

A

Methotrexate
Sulphasalazine
Hydroxychloroquine

38
Q

What are the shortcomings of DMARDs?

A

All have significant adverse effects + require regular blood test monitoring

39
Q

What are 5 major risks with biological therapy?

A

Expensive
All associated with an increase infection risk
TNF-alpha inhibition is associated with increased susceptibility to mycobacterial infections:
TUBERCULOSIS- patients must be screened for TB before starting treatment)
B cell depletion is associated with HEPATITIS B reactivation so patients need to be screened for this
B cell depletion is also associated with JC virus infection + progressive multifocal leukoencephalopathy (PML), RARE

40
Q

List 4 key features of rheumatoid arthritis

A

Chronic
Polyarthritis
Symmetrical
Early morning stiffness in + around joints

41
Q

Describe the character of the swellings in rheumatoid arthritis

A

Soft on palpation

42
Q

List 4 examples of biological therapy for rheumatoid arthritis

A

Inhibition of tumour necrosis factor alpha (TNF alpha)
B cell depletion
Modulation of T cell co-stimulation
Inhibition of IL6

YR2: Musculoskeletal (10 decks)

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