Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
A chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.
Epidemiology of RA.
1%
Higher in smokers
Female > Male 3:1
Peak onset in 5th to 6th decade (workbook says 30-50 yo)
HLA DR4/DR1 linked.
Pathophysiology of RA.
Citrullination of self antigens which are then recognised by T and B cells which can then produce antibodies RF and anti-CCP.
Stimulated macrophages and fibroblasts produce TNFalpha.
The inflammatory cascade leads to proliferation of synoviocytes leading to a boggy joint sweling typical of RA. The synoviocytes grow over the cartilage and lead to restriction of nutrients, this leaves the cartilage damaged.
Activated macrophages stimulate osteoclast differentiation contributing to bone damage.
Typical clinical presentation of RA.
Symmetrical swollen, painful and stiff small joints of hands and feet that is worse in the morning.
The arthritis is progressive, peripheral and symmetrical.
Must have a history of over 6 weeks for diagnosis.
Morning stiffness > 30 mins duration.
Commonly co-exist with fatigue and malaise.
What joints are commonly affected in RA?
MCPs, PIPs and MTPs.
DIPs are typically spared
Hips, knees, shoulders and cervical spine can also be affected but this is less common.
Less common presentation of RA.
Sudden onset with wide spread arthritis
Reccuring mono/polyarthritis of various joints also called palindromic RA.
Persistent monoarthritis of knees, shoulders or hips.
Systemic illnesss with extra-articular symptoms.
Polymyalgic onset.
Recurrent soft tissue problems.
Early signs of RA.
Swollen MCP, PIP, wrist or MTP joints that are often symmetrical.
Look for tenosynovitis or bursitis.
Late signs of RA.
Ulnar deviation and subluxation of the wrist and fingers.
Boutonnieres and Swan-neck deformities
Z-deformity of the thumbs
Hand extensor tendons can rupture
Foot changes are similar
Spinal cord deformity due to atalanto-axial joint subluxation.
Examination of RA.
Soft tissue swelling and tenderness
Ulnar deviation/palmar subluxation of MCPs
Swan-neck and Boutonniere deformity of fingers
Z-deformity of thumbs
Rheumatoid nodules most common at the elbows
Carpal tunnel syndrome.
Investigations of RA.
- RhF (70% of people +ve) and anti-CCP (more sensitive and specific)
- FBCs - normocytic anaemia (anaemia of chronic disease), raised platelets, raised ESR and CRP.
- X-rays
- Ultrasound (more sensitive in early disease)
- MRI (more sensitive in early disease)
- Possible PFTs and HRCTs if there is chest involvement.
X-ray features of RA.
Loss of joint space
Erosions (periarticular)
Soft tissue swelling
Subluxation
When are extra-articular manifestations of RA more common?
If the patient is RF+ and anti-CCP positive.
Since RF+ and Anti-CCP does not offer a definitive diagnosis.
What is it more suitable to use as?
A prognostic factor of the disease.
Extra-articular manifestations of RA.
Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Felty’s syndrome (RA, neutropenia and splenomegaly)
Secondary Sjogren’s Syndrome (AKA sicca syndrome)
Anaemia of chronic disease
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis
Easy way to remember extra articular manifestations of RA.
3Cs
3As
3Ps
3Ss
Criteria for diagnosing RA.
Those with one ore more swollen joints and a suggsetive clinical history not better explained by other disease.
A score of ABCD is done.
6 ore more is diagnostic.
Treatment algorithm according to NICE
