RHEUMATOID ARTHRITIS COPY Flashcards
Define rheumatoid arthritis.
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.
What is rheumatoid factor?
An auto-antibody
What is rheumatoid factor an antibody to?
Rheumatoid factors are antibodies against the Fc portion of IgG.
What isotype of immunoglobulin are rheumatoid factors?
Any. Typically IgM.
Apart from rheumatoid arthritis, when might rheumatoid factor be detected in a patient’s blood? (Name at least 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
Other than rheumatoid factor, what might you look for in the blood of a patient with suspected rheumatoid arthritis?
Anti-CCP
What does anti-ccp stand for?
Anti-cyclic citrullinated peptide
Apart from diagnosis, what might levels of RF (rheumatoid factor) and anti-CCP tell you?
Prognosis. A worse prognosis is associated with raised markers.
What are the risk factors for rheumatoid arthritis? (Name 5)
Genetics Smoking Ebstein-Barr virus (EBV) Human Herpes Virus 6 (HHV-6) Vitamin D deficiency (could be more of a consequence than a cause)
What is the peak age of onset for rheumatoid arthritis?
40-60
What is the ratio of rheumatoid arthritis patients in terms of gender?
More than 2:1 women to men
What are the articular symptoms that a patient with suspected rheumatoid arthritis might present with? (Name at least 4 symptoms)
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.
What are the extra-articular symptoms that a patient with suspected rheumatoid arthritis might present with? (Name 3)
Fatigue Weight loss Fever Pleuritic chest pain Mononeuritis multiplex (odd sensation in different fingers and toes)
Who is more likely to experience the extra-articular symptoms?
Males
What are the early articular signs that a patient with suspected rheumatoid arthritis might present with? (Name 3)
Inflammation of several joints: MCP, PIP, wrist, MTP.
Tenosynovitis
Bursitis
What are the more advanced articular signs that a patient with suspected rheumatoid arthritis might present with? (Name at least 5)
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
What are the more advanced extra-articular signs and complications that a patient with suspected rheumatoid arthritis might present with? (Name at least 5)
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
What is Felty’s syndrome?
Rheumatoid arthritis + splenomegaly + neutropenia
What investigations would you order to explore your patient’s signs and symptoms and what might they show?
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.
What are the pain relieving drugs used with rheumatoid arthritis patients? For each class give an example of a drug commonly used.
NSAIDs - ibuprofen
Paracetamol
Opiates - codeine, tramadol
Are DIP joints often affected in rheumatoid arthritis?
No. This is more in osteoarthritis.
What percentage of rheumatoid arthritis patients are seropositive for rheumatoid factor?
Only about 70%.
What is the specificity of anti-ccp in rheumatoid arthritis patients?
Very high. About 98%.
Apart from anti-CCP and RF, what other plasma autoantibodies might rheumatoid arthritis patients be seropositive for?
ANA (Antinuclear antibody)
ANCA (Antineutrophil cytoplasmic antibody)
What is the DAS28 and what is it used for?
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.
Beyond pain relief, what medication might be given to someone recently diagnosed with rheumatoid arthritis?
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.
What is a major cause of the reduced life expectancy of patients with RA?
Increased atherosclerosis
What are the major cell types involved in the inflammation of the synovial in RA?
T-lymphocytes Macrophage like (type A) synoviocytes Fibroblastic (type B) synoviocytes
What can we say about prognosis of those RA patients without positive autoantibodies vs those with?
The prognosis of those who present as sero-negative is better.
What is the gene involved in rheumatoid arthritis?
HLA-DR4
