Rheumatoid Arthritis Flashcards

Question

What is the pathogenesis of RA?

Answer 1

Synovial membrane is abnormal in rheumatoid arthritis: | The synovium becomes a proliferated mass of tissue (pannus

Answer 2

validated by the therapeutic success of TNFα inhibition in this condition

Answer 3

TNFα inhibition is achieved through parenteral administration (most commonly sub-cutaneous injection) of antibodies or fusion proteins

Answer 4

Polyarthritis - swelling of the small joints of the hand and wrists is common Symmetrical Early morning stiffness in and around joints May lead to joint damage and destruction - ‘joint erosions’ on radiographs

Answer 5

Rheumatoid nodules | Others rare e.g. vasculitis, episcleritis

Answer 6

Rheumatoid factor Autoantibody against IgG - should really call this rheumatoid ‘antibody’ not ‘factor’

Answer 7

Affects small and large joints, but particularly hands and feet Symmetrical Affects multiple joints (polyarthritis)

Answer 8

``` Metacarpophalangeal joints (MCP) Proximal interphalangeal joints (PIP) Wrists Knees Ankles Metatarsophalangeal joints (MTP) ```

Answer 9

joint synovitis tenosynovitis bursa

Answer 10

Fever, weight loss | Subcutaneous nodules

Answer 11

vasculitis Ocular inflammation e.g. episcleritis Neuropathies Amyloidosis Lung disease – nodules, fibrosis, pleuritis Felty’s syndrome – triad of splenomegaly, leukopenia and rheumatoid arthritis

Answer 12

Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue Occur in ~30% of patients

Answer 13

Severe disease Extra-articular manifestations Rheumatoid factor

Answer 14

Antibodies that recognize the Fc portion of IgG as their target antigen typically IgM antibodies i.e. IgM anti-IgG antibody Positive in 70% at disease onset and further 10-15% become positive over the first 2 years of diagnosis

Answer 15

Antibodies to citrullinated protein antigens

Answer 16

highly specific for rheumatoid arthritis Anti-cyclic citrullinated peptide antibody ‘anti-CCP antibody’ Citrullination of peptides is mediated by enzymes termed: Peptidyl arginine deiminases (PADs)

Answer 17

Prevent joint damage

Answer 18

Early recognition of symptoms, referral and diagnosis Prompt initiation of treatment: joint destruction = inflammation x time Aggressive treatment to suppress inflammation

Answer 19

Disease-modifying anti-rheumatic drugs (‘DMARDs’) = drugs that control the disease process

Answer 20

1st line treatment: | methotrexate in combination with hydroxychloroquine or sulfasalazine

Answer 21

2nd line: Biological therapies offer potent and targeted treatment strategies New therapies include Janus Kinase inhibitors : Tofacitinib & Baricitinib

Answer 22

Important roles for glucocorticoid therapy (prednisolone) but avoid long-term use because of side-effects.

Answer 23

Multidisciplinary approach also important e.g. physiotherapy, occupational therapy, hydrotherapy, surgery

Answer 24

Biological therapies are proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

Answer 25

Seronegative spondyloarthropathy – no positive autoantibodies Chronic sacroillitis – inflammation of sacroiliac joints Results in spinal fusion – ankylosis Common demographic: 20-30yrs, M Associated with HLA B27

Answer 26

``` Lower back pain + stiffness Early morning Improves with exercise Reduced spinal movements Peripheral arthritis Plantar Fasciitis, Achilles Tendonitis Fatigue ```

Answer 27

Hyperextended neck Loss of Lumbar lordosis Flexed hips and knees

Answer 28

Normocytic anaemia Raised CRP, ESR HLA-B27

Answer 29

X-rays | MRI

Answer 30

Squaring Vertebral bodies, Romanus lesion Erosion, sclerosis, narrowing SIJ Bamboo Spine Bone Marrow Oedema

Answer 31

Physiotherapy Exercise regimes NSAIDs Peripheral joint disease - DMARDs

Answer 32

autoimmune disease affecting the skin (scaly red plaques on extensor surfaces eg elbows and knees)

Answer 33

~10% of psoriasis patients also have joint inflammation Unlike RA, rheumatoid factors are not present (“seronegative”) Varied clinical presentations:

Answer 34

Classically asymmetrical arthritis affecting IPJs

Answer 35

- Symmetrical involvement of small joints (rheumatoid pattern) - Spinal and sacroiliac joint inflammation - Oligoarthritis of large joints - Arthritis mutilans

Answer 36

X-rays of affected joints – pencil in cup abnormality MRI – sacroiliitis and enthesitis Bloods – no antibodies as seronegative

Answer 37

DMARDs – methotrexate Avoid oral steroids – risk of pustular psoriasis due to skin lesions

Answer 38

Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections

Answer 39

Enthesitis (tendon inflammation) Skin inflammation Eye inflammation

Answer 40

HIV | Hep C

Answer 41

Commonly young adults with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)

Answer 42

Symptoms follow 1-4 weeks after infection and this infection may be mild

Answer 43

Condition is usually self-limiting – can be managed with NSAIDS or DMARDs if required

Answer 44

a multi-system autoimmune disease Multi-site inflammation: can affect any almost any organ. Often joints, skin, kidneys, haematology. Also: lungs, CNS involvement

Answer 45

with antibodies to self antigens (‘autoantibodies’) | Autoantibodies are directed against components of the cell nucleus (nucleic acids and proteins)

Answer 46

1. Antinuclear antibodies (ANA): High sensitivity for SLE but not specific. A negative test rules out SLE, but a positive test does not mean SLE. 2. Anti-double stranded DNA antibodies (anti-dsDNA Abs): High specificity for SLE in the context of the appropriate clinical signs

Answer 47

F:M ratio 9:1 Presentation 15 - 40 yrs Increased prevalence in African and Asian ancestry populations Prevalence varies 4-280/100,000