Rheumatoid Arthritis & Seronegative Spondyloarthropathies Flashcards
RA is an autoimmune disease that targets _____ tissues in _______ joints
Synovial; diarthrodial
Systemic features of RA
Fatigue, fever, normochromic normocytic anemia
Elevated APPs (ESR, CRP)
Constitutional sxs: malaise, myalgia, depression
1/3 of pts are susceptible to RA d/t genetic factors — typically _______ alleles
HLA-DRB 4
T/F: pathologic changes in joints precede synovitis in RA pts by 5-10 years
True
Initial pathogenesis of RA involves infiltration of leukocytes, cytokines, and macrophages that act as APCs to activate _____ cells.
Later _____ cells produce autoantibodies, and proinflammatory cytokines promote synovial proliferation, increase synovial fluid, and lead to _______ formation that invades cartilage and bone
T
B; pannus
Imaging studies to order when RA is suspected
X-rays of hands and feet — detect symmetrical involvement of MCP/MTP joints; erosions
CT is more sensitive in detecting erosions!!
Treatment for RA that presents acutely
Begin NSAID for pain control
Early use of DMARD
May need low dose steroid for a few weeks
Monitor progress and toxicity
How does RA change during pregnancy?
Improves; then flares 4-6 weeks post partum
Significant mortality caused by infection, renal disease, GI disease, heart disease, and malignancy is associated with RA moreso than the general population.
What are cardiac mortality associations with RA?
CAD, CHF due to endothelial damage from chronic inflammation
In terms of the 2010 RA Classification Criteria, the target population of those who should be tested are patients who:
Have at least 1 joint with definite clinical ______ that is not better explained by another disease
Synovitis
What are the 4 class criteria utilized in the 2010 RA Classification Criteria?
Joint involvement (number and size)
Serology (at least 1 positive test — RF, CCP)
Acute phase reactants (at least 1 test needed — CRP, ESR)
Duration of symptoms (>6 weeks gets a point)
[greater than 6/10 points = definite RA]
What lab values are used to monitor treatment response in RA?
Acute phase reactants (ESR, CRP)
What part of the spine is affected by RA?
C1-C2 — be careful with flexion and hyperextension; tell anesthesiologist before intubation d/t risk of subluxation!
[the remainder of the axial spine is SPARED!]
T/F: RA pts have decreased risk of osteoporosis
False, they have increased risk
______ deviation of the wrist in RA in addition to synovial proliferation may lead to compression of the ____ nerve and subsequent carpal tunnel syndrome
Radial; median
Knee manifestations of RA
Bakers cyst — popliteal region
Diagnosis of RA typically requires active signs of inflammation of at least _________ duration
6 weeks
Complication of RA characterized by tender reddish purple papule; leads to necrotic, non-healing ulcer
Pyoderma gangrenosum
Purpura, petechiae, splinter hemorrhages, and digital infarcts are characteristic of rheumatoid ______
Vasculitis
T/F: Rheumatoid arthritis is an independent risk factor for CAD
True
_____ syndrome = nodular lung densities after exposure to coal or silica dust
Caplan
Sjogren’s syndrome is seen in 35% of pts with RA. What are 3 tests that may be used to support a dx of Sjogrens?
Ro/SS-a, La/SS-b Abs
Schirmers test (litmus paper under eyelids to test for tear production)
Slit-lamp exam
Rheumatoid arthritis Splenomegaly Thrombocytopenia Neutropenia Fever Anemia RF and anti-CCP positive
Felty’s syndrome
RA may be complicated by atlantoaxial subluxation (C1/C2) due to erosion of the _________ _______; other complications include peripheral neuropathy and ______ myelopathy
Odontoid process; cervical
In which of the following might rheumatoid factor be positive?
A. Healthy elderly patient B. Hepatitis B/C pts C. CTD/SLE D. Polymyositis E. Sjogrens F. Systemic sclerosis G. Lymphoma or myeloma H. TB, mono, syphilis, and sarcoid I. All of the above
I. All of the above
Immunosuppresive drug class utilized in RA that can halt disease progression in synovium and halt/slow radiographic progression; treat to target — remission or low disease activity
DMARDs
One of the non-biologic DMARDs used in RA is methotrexate — this is the drug recommended as the first DMARD for RA/once a week. Pts on this drug should be given supplemental _______.
It is also useful in psoriatic arthritis.
It should not be given in pregnancy
Folic acid
Labs to monitor while pt is on MTX for RA
CBC
LFTs
Creatinine
Monitor q4-8 weeks
[toxicities include hepatic, myelosuppression, pulmonary]
Another non-biologic used in tx of RA is hydroxychloroquine (antimalarial) which is safe in pregnancy. This agent can also be used with MTX and sulfasalazine. What specialist should pts on hydroxychloroquine follow up with?
Ophthalmologist d/t risk of macular damage to retina, blurred vision, halos, photophobic
What RA drug?:
Pyrimidine antagonist
Rapid excretion with cholestyramine
Don’t use when pregnant
GI/hepatic toxicity/teratogenic
Leflunomide
Sulfasalazine is also effective in RA and can be used with MTX. It is safe in pregnancy. What lab should be monitored on this drug?
WBC
Toxicities of all biologics used in RA
Increased risk of infection
Reactivation of latent TB
Neoplasia
Multiple sclerosis
Autoimmune disease
Pro-inflammatory cytokine in RA pathogenesis that stimulates synovial cell proliferation and collagenase
TNF-alpha
Anti-TNF agents used in RA
Etanercept
Inflixumab
Adalimumab
Rituximab
Overall management of RA
Define extent of joint and extra-articular involvement
Full dose NSAID
Early use of DMARD (MTX w/i 3-6 month window)
Add a biologic
Low dose steroids for flares/bridge
Adequate pain management
Monitor progress/toxicity
Enteropathic arthritis and spondylitis develops in 20% of pts with either _____ or ______; this condition responds to treatment with ______
Crohns; UC; infliximab
Clinical manifestations of spondyloarthropathies
Predilection for spine, SI joints
New bone formation at sites of inflammation
Joint ankylosis; fusion, rigidity, kyphosis
Asymmetric peripheral arthritis
Enthesitis
Ocular inflammation
_______ = inflammation of insertion points of tendons and ligaments onto bones; component of spondyloarthropathies
Seronegative spondyloarthropathies may be related to immune susceptibility via allele _____
Enthesitis
HLA-B27
______ = swelling of finger or toe; commonly seen in reactive arthritis/psoratic arthritis
Dactylitis
Keratoderma is a skin manifestation of _______ arthritis
Reactive
2 types of chronic polyarthritis with symmetric SI involvement and smooth, marginal syndesmophyte
Ankylosing spondylitis
Enteropathic arthrities
2 types of chronic polyarthritis with asymmetric SI involvement and course, non-marginal syndesmophyte
Psoriatic arthritis
Reactive arthritis
M:F ratio of RA, ankylosing spondylitis, enteropathic arthritis, psoriatic arthritis, and reactive arthritis
Rheumatoid — 1:3 (F)
AS — 3:1 (M)
EA — 1:1 (=)
PA — 1:1 (=)
Reactive — 10:1 (M)
[M:F]
Eye manifestations of RA, ankylosing spondylitis, and reactive arthritis
Rheumatoid — scleritis
AS — iritis
Reactive — iritis and conjunctivitis
Hallmark of spondyloarthropathy in children
Enthesitis — examples include plantar fasciitis, achilles tendonitis, costochondritis
Not all pts with spondyloarthropathies are positive for HLA-B27. Which of the spondyloarthropathies is 90% positive for HLA-B27?
Ankylosing spondylitis
[reactive arthritis is positive 80% of the time, enteropathic spondylitis is 75%, psoriatic arthritis is 50%]
What is the importance of asking if physical activity improves a young male pts’ SI joint pain?
If exercise makes it better, it is NOT DJD, and more likely to be AS
Tests/imaging to order in a pt you suspect may have ankylosing spondylitis
HLA-B27
CRP, ESR
CBC
X-rays of pelvis — attention SI joints (shows erosions of SI joints, pseudo-widening, sclerosis, fusion, ankylosis, etc)
X-rays of lumbar vertebrae (shows squaring — loss of anterior convexity, and shiny corners = sclerosis at edge of vertebral bodies)
CT of lumbar/pelvis if X-rays non-diagnostic
Most common inflammatory disorder of axial skeleton
Ankylosing spondylitis
Clinical manifestations of ankylosing spondylitis
Low back pain >3 mos
Morning stiffness, improved with exercise, worse with rest
Fatigue, weight loss, fever
Symmetrical SI joint pain (sacroiliitis); loss of mobility/flexibility; arthritis of hips
Tendonitis, plantar fasciitis
Extra-articular manifestations of ankylosing spondylitis
Anterior uveitis (iritis)
Photophobia, eye pain, blurred vision
Aortic insufficiency, aortic aneurysm
Pulmonary fibrosis — restrictive
IBD
Psoriasis
[NOTE: iritis is NOT found in RA, but may be seen with SLE or herpes simplex]
2 special tests that may be performed on PE to identify ankylosing spondylitis
Schober Test — restricted forward flexion; measures 5 cm below and 10 cm above LS junction while pt bends forward. Less than 4 cm = decreased mobility
FABERE test — decreased chest expansion if less than 5 cm
ESR, CRP, HLA, CBC, RF, ACCP, and ANA results in ankylosing spondylitis
ESR and CRP increased
HLA-B27 positive in 90%
CBC shows Anemia of chronic disease
Negative RF, ACCP, ANA
_______ = bony growth originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae
Syndesmophytes
The differential diagnosis for ankylosing spondylitis includes _________, which causes calcification along the lateral aspect of 4 contiguous vertebral bodies but does NOT affect the SI joints
DISH (diffuse idiopathic skeletal hyperosteosis)
The differential diagnosis for ankylosing spondylitis includes _________, which affects young and middle aged females; manifestations include NORMAL SI joints; x-ray shows sclerosis on iliac side of SI joint
Osteitis condensans ilii
Late complications of ankylosing spondylitis include _________ lung disease, _______ fractures, and __________ syndrome evidenced by bowel/bladder dysfunction and pelvis+low back pain
Restrictive; compression; cauda equina
Treatment for ankylosing spondylitis
Exercise, PT, swimming, stretching (preserve mobility/prevent kyphosis)
NSAID — pain control, may slow damage progression
TNF-a inhibitors — decrease inflammation of axial spine and improve mobility (helps in 50% of pts)
Non-biologic DMARDs — MTX/sulfasalazine for peripheral arthritis but NOT axial dz
Autoimmune disease; asymmetric mono-arthritis or oligo-arthritis (large joints) in lower extremities; may be associated with GI/GU infection — salmonella, shigella, yersinia, campylobacter, chlamydia trachomatis
Reactive arthritis
Features of reiter’s syndrome/reactive arthritis
Urethritis
Arhtritis
Conjunctivitis (uveitis)
May also see mucocutaneous lesions (oral ulcers)
Manifestations of reactive arthritis may include _____ _____ which are vesicles/ulcers on the glans penis, as well as _____ _____ which are painless eruptions on the palms and soles
Circunate balanitis
Keratoderma blennorrhagicum
Reactive arthritis treatment
Usually self-limited (6 months)
NSAID, steroids (intraarticular)
If chronic progression, use DMARD (sulfasalazine, MTX, leflunomide)
Urethritis — if chlamydia, tx with azithromycin or doxycycline
Pencil in cup deformity on x-ray
Psoriatic arthritis
Treatment for psoriatic arthritis
NSAID - pain control
Non-biologic DMARD — for peripheral arthritis
Biologics (TNF inhib) - prevent progression of joint damage/psoriasis
Typically combine MTX with TNF-inhibitor, inflixumab, etanercept
In enteropathic arthritis/IBD-associated arthritis, the peripheral arthritis typically parallels the activity of IBD, affects _____ joints of the lower extremity, and _____ joints of the upper extremity.
All extra-articular manifestations occur more commonly in _______
50-75% of pts are HLA-B27 positive
Large; small
Crohns disease
Extraarticular manifestations of enteropathic arthritis/IBD-associated arthritis (skin, eyes, GI, GU, CV, bones)
Skin — pyoderma gangrenosum, erythema nodosum
Eyes — uveitis
GI — CD/UC
GU — nephrolithiasis
CV — thromboembolism
Bones — fracture, low bone density, vit D deficiency
Treatment for enteropathic arthritis/IBD-associated arthritis
NSAID
Steroids — short relief
MTX/sulfasalazine
TNF-a inhib are effective for IBD arth
