Rheumatoid Arthritis + Sero negative spondyloarthropathies Flashcards
1
Q
% of women affected by RA
A
3%
2
Q
% of men affected by RA
A
1%
3
Q
Genetic link - RA
A
HLA - DR4
4
Q
What is the most important environmental factor in RA?
A
Smoking
5
Q
WHEN IS IT NOT RA (5)
A
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
6
Q
typical age of onset
A
30-50 y/o
7
Q
PS RA
A
Symmetrical polarthritis Of small joints Red, warm + painful joints Worse in AMs + stiff Malaise, W loss + disturbed sleep \+/- extra-articular features
8
Q
What % of pt w/ RA have rapid onset
A
15%
9
Q
O/E RA
A
Warm, swollen + tender joints
+ve squeeze sign
Reduced grip strength bilaterally
10
Q
DDx RA (4)
A
Reactive arthritis
Sero -ve
Polymyalgia rheumatica
Nodal RA
11
Q
Where is the most common place to get RA?
A
Hands
12
Q
Characteristic hand deformities RA
A
Ulnar deviation at MCPJ Radial deviation at wrist Boutonniers Swan neck deformity Z deformity thumb Subluxation (late
13
Q
What is a Boutonniere deformity (RA)
A
PIP hyperflexed
DIP hyperextended
14
Q
What is a Swan Neck deformity (RA)
A
PIP hyperextended
DIP hyperflexed
15
Q
progression of RA in the feet
A
MTPJ swelling –> hammer toe deformity
+/- ulcers/callouses
16
Q
Which large joint is most commonly affected by RA?
A
knee
17
Q
Clinical assessment tool RA
A
DAS 28
18
Q
What are the 4 domains of the DAS 28
A
Joint distribution
Serology
Sx duration
Acute phase reactants
19
Q
Ix bloods - RA (5)
A
RF Anti-CCP ANA FBC CRP/ESR
20
Q
other Ix RA (apart from bloods - 2)
A
Joint aspiration
Xray
21
Q
Xray findings RA (5)
A
Uniform joint space narrowing Periarticular erosions subluxation/dislocation soft tissue swelling Juxta-articular osteopenia
22
Q
1st changes RA
A
Rheumatoid synovitis –> villious pattern in synovium+ neutrophil infiltration
23
Q
What does the pannus do in RA
A
Destroys articular cartilage
Focal destruction of bone –> erosions
L term - destroys + replaces whole cartilage –> 2’ OA
24
Q
1st line Mx RA
A
DMARD ASAP
Methotrexate + hydroxychloroquine
+NSAIDS
25
indication - biologics in RA
if 2 DMARDs have already been tried
| If DAS >5.5
26
Extra Mx RA (5)
```
Give up smoking
Flu jb
Importance of monitoring/reg blood tests
Sick day rules
Pregnancy
```
27
What % of pt w/ RA have Rh nodules
20%
28
typically where are rheumatoid nodules found
Olecranon
Calcaneum
MCPJ
29
What is the most common pulmonary sequalae in RA
Pulmonary fibrosis
30
Which RA Tx can cause pulmonary fibrosis
methotrexate
31
Where do you find vasculitis caused by RA (3)
nail-fold infarcts
Bowel infarction
Widespread cutaneous vasculitis
32
what % of RA pt have peri-cardial involvement
30-40%
33
nervous system impact - RA (2)
Entrapment neuropathies e.g. carpal tunnel
| Glove + stocking sensory loss
34
Effect on eyes of RA
Dry eyes
| SScleritis/episcleritis
35
Effect on kidneys of RA
Amyloidosis --> nephrotic syndrome + RF
36
Haemotological effect - RA (2)
Felty's syndrome
| Normocytic normochromic anaemia
37
What % w/ RA of the cervical spine get A-A subluxation
50-80%
38
What occurs in Atlanto-axial subluxation
transverse + apical ligaments are destroyed by pannus
39
PS A-A subluxation (3)
Localised pain
Deformity
Cervical radiculopathy
40
Ix A-A subluxation (2)
XR- AP, lat + Odontoid peg
| MRI C spine
41
Mx A-A subluxation (2)
Surgical decompression spinal cord
| Stabilise segment spine
42
Which genetic linkage do Seronegative spondyloarthropathies all have in common
HLA B27
43
Seronegative spondyloarthropathies (4)
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
IBD related arthropathy
44
PS Ankylosing spondylitis
Episodic inflammation of SIJ in young adults
Pain/stiffness lower back/bum - worse in AM + relieved by exercise
Asymp between episodes
45
Who gets ankylosing spondylitis?
M 3:1
| 20-40 y/o
46
LFM ankylosing spondylitis
L:Question mark posture
F: Pain on P over SIJ
M: Limited lateral + forward flexion of lumbar spine
47
WHy do pt w/ AS get the question mark posture?
Lumbar lordosis + paraspinal mm wasting
48
Tests AS (3)
Schober
Sacroiliac stress test
Tragus to wall
49
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
50
Joints involved - AS
SIJ
Hip + shoulder
Costochondral joints
51
Extra-articular manifestations AS (The A's) (6)
```
Apical fibrosis
Anterior uveitis
Aortic regurg
Amyloidosis
AV node blood
Achilles Tendonitis
```
52
Clinical assessment of AS
BAS DAI
53
Ix AS (3)
ESR (norm 50%)
Pelvic XR -
Spinal XR -
54
Pelvic XR findings AS
Bilateral sacroilitis
55
Spinal XR findings AS
Bamboo spine (square vertebral bodies)
ossification of ligaments
Straightening of anterior line
56
Mx AS
NSAIDs 6w
57
2nd line Mx AS
If no improvement after 2 NSAIDS
| Biologics
58
When should biologics be stopped in AS
If after 12 weeks there is no improvement
59
What are the 5 subtypes of psoriatic arthritis
```
Symmetrical polyarthritis
Asymmetrical oligoarhtritis
DIPJ predominant
Spondylitis
Arthritis mutilans
```
60
Psoriatic arthritis - symmetrical polyarthritis
Similar to RA
| But DIPJ involvement + < severe
61
Psoriatic arthritis - asymmetrical oligoarthritis
<5 joints
62
Psoriatic arthritis - DIPJ predominant (3)
Ttpical
Assoc w/ signif nail changes
--> Dactylitis
63
Psoriatic arthritis - spondylitis
Affects spine +/- SIJ
64
Psoriatic arthritis - arthritis mutilans
Severe
| --> joint destruction + deformity
65
XR appearance sporiatic arthritis (6)
```
Minimal osteopenia
Proliferative erosions
Uniform narrowing
Soft tissue swellings
DIPJ
Pencil in cup deformities
```
66
Clinical assessment psoriatic arthritis
DAS 66/68
67
Mx psoriatic arthritis - 1 joint
Full dose NSAID +/- injection
68
Mx psoriatic arthritis - mulitiple joints
Mx like RA incl methotrexate
69
Another name for reactive arthritis
Reiter's syndrome
70
What does Reactive arthritis occur because of ?
Infection - GI/GUM
71
How long after infection does reactive arthritis occur
4-40 days
72
Pathogens that cause reactive arthritis (4)
Chlamydia
Salmonella
Campylobacter
Gonococcus
73
Gender predominance reactive arthritis
Males
74
Triad - reactive arthritis PS
Can't see, pee or climb a tree
Conjunctivitis
Dysuria
Lower limb oligoarthritis
75
What can reactive arthritis develop into?
Chronic arthritis
76
Skin lesions common w/ reactive arthritis (2)
Keratoderma blenorrhagica
| Balanitis
77
Mx (1st line) reactive arthritis
NSAID + steroid injection
78
2nd line Mx reactive arthritis
Sulfasalazine
79
What % of people w/ IBD develop arthropathy
10-15%
80
PS IBD-related arthropathy
Symmetrical arthritis of lower limbs
| 5% = spinal
81
Arhtropathy + UC
If in remission --> remission of joint disease
82
Arthropathy + Chrons
Even if chrons well controlled, arthropathy can persist
