Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

A chronic autoimmune inflammation of joints and synovium

Question 2

Describe the arthritic symptoms of rheumatoid arthritis

Answer 2

Symmetrical swelling of joints

Stiff in the morning

Question 3

What are the consequences of rheumatoid arthritis and how are these seen on radiographs?

Answer 3

Joint damage and destruction, seen as joint erosions

Question 4

Which joints are commonly affected?

Answer 4

MCP
PIP
Cervical spine
Wrists
Elbow
Shoulder
Hip
Knees
Ankles
MTP

Question 5

How many joints are affected in rheumatoid arthritis and what do you call this?

Answer 5

Polyarthritis - many joints affected

Question 6

What can happen as a result of joint deformity in the foot?

Answer 6

Callus formation

Question 7

What do you call hyperflexion of DIPs?

Answer 7

Swan-neck deformity

Question 8

What do you call hyperflexion of PIPs?

Answer 8

Boutonniere’s deformity

Question 9

What radiographic changes are seen in rheumatoid arthritis?

Answer 9

Ulnar deviation of the phalanges

Question 10

What else is affected besides joints, and what do you see as a result?

Answer 10

Synovium:
Synovitis
Tenosynovitis e.g. of extensors in hands
Bursitis e.g. olecranon bursitis

Question 11

What nodules do you see in rheumatoid arthritis?

Answer 11

External - subcutaneous, next to ulnar near elbow

Internal - fibroids

Question 12

Explain the pathology of subcutaneous nodes

Answer 12

Central area of fibrinoid necrosis

Surrounded by histiocytes and connective tissues

Question 13

What is Rheumatoid factor?

Answer 13

IgM antibody

Question 14

What is rheumatoid factor mounted against?

Answer 14

IgM against IgG

Question 15

What percentage of patients have positive RF on diagnosis?

Answer 15

70%
15% develop it later
the rest are seronegative

Question 16

What other highly specific antibodies are screened for in rheumatoid arthritis?

Answer 16

Anti-ccp

Question 17

What is anti-ccp?

Answer 17

Antibodies against citrullinated peptides

Question 18

What are citrullinated peptides and how do they form?

Answer 18

Arginine amino acid of peptides is converted to citrulline by peptidyl arginine deiminase (PADs)

Question 19

Why do anti-CCPs develop in RA?

Answer 19

PADs are present in neutrophils and monocytes, which are recruited to the synovium. Therefore there is an increased citrullination of autologous peptides in the inflammed synovium.

Question 20

Which environmental factors accelerate the formation of citrulline?

Answer 20

Smoking

Question 21

Which gene is associated with RA?

Answer 21

HLA-DRb

Question 22

State the major cytokine involved in pannus formation

Answer 22

TNF alpha

Question 23

What is pannus?

Answer 23

Infiltration of the synovium

Question 24

List the three main categories of treatment for RA

Answer 24

DMARDs
Glucocorticoids
Biologics

Question 25

Give four examples of biologics used to treat RA

Answer 25

anti TNF B cell depletion (anti CD20) Modulation of T cell costimulation IL6 inhibition

Question 26

Give some common extra articular features of RA

Answer 26

Fever Weight loss Subcutaneous nodules

Question 27

Give some uncommon extra articular features of RA

Answer 27

``` Neuropathies Amyloidosis Lung disease Felty's syndrome Vasculitis Ocular inflammation ```

Question 28

What is Felty's syndrome?

Answer 28

Splenomegaly Leukopenia RA TRIAD

Question 29

Which joints are commonly spared in rheumatoid arthritis?

Answer 29

DIP thoracic spine lumbar spine