Rheumatoid Arthritis + Sero negative spondyloarthropathies Flashcards
% of women affected by RA
3%
% of men affected by RA
1%
Genetic link - RA
HLA - DR4
What is the most important environmental factor in RA?
Smoking
WHEN IS IT NOT RA (5)
Never involves DIPs Never involves lower back Never involves big toes in isolation Doesn't cause plantar fascitis or achilles tendonitis Doesn't cause isolated neck pain
typical age of onset
30-50 y/o
PS RA
Symmetrical polarthritis Of small joints Red, warm + painful joints Worse in AMs + stiff Malaise, W loss + disturbed sleep \+/- extra-articular features
What % of pt w/ RA have rapid onset
15%
O/E RA
Warm, swollen + tender joints
+ve squeeze sign
Reduced grip strength bilaterally
DDx RA (4)
Reactive arthritis
Sero -ve
Polymyalgia rheumatica
Nodal RA
Where is the most common place to get RA?
Hands
Characteristic hand deformities RA
Ulnar deviation at MCPJ Radial deviation at wrist Boutonniers Swan neck deformity Z deformity thumb Subluxation (late
What is a Boutonniere deformity (RA)
PIP hyperflexed
DIP hyperextended
What is a Swan Neck deformity (RA)
PIP hyperextended
DIP hyperflexed
progression of RA in the feet
MTPJ swelling –> hammer toe deformity
+/- ulcers/callouses
Which large joint is most commonly affected by RA?
knee
Clinical assessment tool RA
DAS 28
What are the 4 domains of the DAS 28
Joint distribution
Serology
Sx duration
Acute phase reactants
Ix bloods - RA (5)
RF Anti-CCP ANA FBC CRP/ESR
other Ix RA (apart from bloods - 2)
Joint aspiration
Xray
Xray findings RA (5)
Uniform joint space narrowing Periarticular erosions subluxation/dislocation soft tissue swelling Juxta-articular osteopenia
1st changes RA
Rheumatoid synovitis –> villious pattern in synovium+ neutrophil infiltration
What does the pannus do in RA
Destroys articular cartilage
Focal destruction of bone –> erosions
L term - destroys + replaces whole cartilage –> 2’ OA
1st line Mx RA
DMARD ASAP
Methotrexate + hydroxychloroquine
+NSAIDS
indication - biologics in RA
if 2 DMARDs have already been tried
If DAS >5.5
Extra Mx RA (5)
Give up smoking Flu jb Importance of monitoring/reg blood tests Sick day rules Pregnancy
What % of pt w/ RA have Rh nodules
20%
typically where are rheumatoid nodules found
Olecranon
Calcaneum
MCPJ
What is the most common pulmonary sequalae in RA
Pulmonary fibrosis
Which RA Tx can cause pulmonary fibrosis
methotrexate
Where do you find vasculitis caused by RA (3)
nail-fold infarcts
Bowel infarction
Widespread cutaneous vasculitis
what % of RA pt have peri-cardial involvement
30-40%
nervous system impact - RA (2)
Entrapment neuropathies e.g. carpal tunnel
Glove + stocking sensory loss
Effect on eyes of RA
Dry eyes
SScleritis/episcleritis
Effect on kidneys of RA
Amyloidosis –> nephrotic syndrome + RF
Haemotological effect - RA (2)
Felty’s syndrome
Normocytic normochromic anaemia
What % w/ RA of the cervical spine get A-A subluxation
50-80%
What occurs in Atlanto-axial subluxation
transverse + apical ligaments are destroyed by pannus
PS A-A subluxation (3)
Localised pain
Deformity
Cervical radiculopathy
Ix A-A subluxation (2)
XR- AP, lat + Odontoid peg
MRI C spine
Mx A-A subluxation (2)
Surgical decompression spinal cord
Stabilise segment spine
Which genetic linkage do Seronegative spondyloarthropathies all have in common
HLA B27
Seronegative spondyloarthropathies (4)
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
IBD related arthropathy
PS Ankylosing spondylitis
Episodic inflammation of SIJ in young adults
Pain/stiffness lower back/bum - worse in AM + relieved by exercise
Asymp between episodes
Who gets ankylosing spondylitis?
M 3:1
20-40 y/o
LFM ankylosing spondylitis
L:Question mark posture
F: Pain on P over SIJ
M: Limited lateral + forward flexion of lumbar spine
WHy do pt w/ AS get the question mark posture?
Lumbar lordosis + paraspinal mm wasting
Tests AS (3)
Schober
Sacroiliac stress test
Tragus to wall
Schober test
With pt standing, mark the skin overlying 5th spinous process, and also 10cm above i. On forward flexion, this should increase to >15cm
Joints involved - AS
SIJ
Hip + shoulder
Costochondral joints
Extra-articular manifestations AS (The A’s) (6)
Apical fibrosis Anterior uveitis Aortic regurg Amyloidosis AV node blood Achilles Tendonitis
Clinical assessment of AS
BAS DAI
Ix AS (3)
ESR (norm 50%)
Pelvic XR -
Spinal XR -
Pelvic XR findings AS
Bilateral sacroilitis
Spinal XR findings AS
Bamboo spine (square vertebral bodies)
ossification of ligaments
Straightening of anterior line
Mx AS
NSAIDs 6w
2nd line Mx AS
If no improvement after 2 NSAIDS
Biologics
When should biologics be stopped in AS
If after 12 weeks there is no improvement
What are the 5 subtypes of psoriatic arthritis
Symmetrical polyarthritis Asymmetrical oligoarhtritis DIPJ predominant Spondylitis Arthritis mutilans
Psoriatic arthritis - symmetrical polyarthritis
Similar to RA
But DIPJ involvement + < severe
Psoriatic arthritis - asymmetrical oligoarthritis
<5 joints
Psoriatic arthritis - DIPJ predominant (3)
Ttpical
Assoc w/ signif nail changes
–> Dactylitis
Psoriatic arthritis - spondylitis
Affects spine +/- SIJ
Psoriatic arthritis - arthritis mutilans
Severe
–> joint destruction + deformity
XR appearance sporiatic arthritis (6)
Minimal osteopenia Proliferative erosions Uniform narrowing Soft tissue swellings DIPJ Pencil in cup deformities
Clinical assessment psoriatic arthritis
DAS 66/68
Mx psoriatic arthritis - 1 joint
Full dose NSAID +/- injection
Mx psoriatic arthritis - mulitiple joints
Mx like RA incl methotrexate
Another name for reactive arthritis
Reiter’s syndrome
What does Reactive arthritis occur because of ?
Infection - GI/GUM
How long after infection does reactive arthritis occur
4-40 days
Pathogens that cause reactive arthritis (4)
Chlamydia
Salmonella
Campylobacter
Gonococcus
Gender predominance reactive arthritis
Males
Triad - reactive arthritis PS
Can’t see, pee or climb a tree
Conjunctivitis
Dysuria
Lower limb oligoarthritis
What can reactive arthritis develop into?
Chronic arthritis
Skin lesions common w/ reactive arthritis (2)
Keratoderma blenorrhagica
Balanitis
Mx (1st line) reactive arthritis
NSAID + steroid injection
2nd line Mx reactive arthritis
Sulfasalazine
What % of people w/ IBD develop arthropathy
10-15%
PS IBD-related arthropathy
Symmetrical arthritis of lower limbs
5% = spinal
Arhtropathy + UC
If in remission –> remission of joint disease
Arthropathy + Chrons
Even if chrons well controlled, arthropathy can persist
