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MSK II Exam II > Rheumatoid Arthritis & Seronegative Spondyloarthropathies > Flashcards

Rheumatoid Arthritis & Seronegative Spondyloarthropathies Flashcards

1
Q

RA is an autoimmune disease that targets _____ tissues in _______ joints

A

Synovial; diarthrodial

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2
Q

Systemic features of RA

A

Fatigue, fever, normochromic normocytic anemia

Elevated APPs (ESR, CRP)

Constitutional sxs: malaise, myalgia, depression

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3
Q

1/3 of pts are susceptible to RA d/t genetic factors — typically _______ alleles

A

HLA-DRB 4

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4
Q

T/F: pathologic changes in joints precede synovitis in RA pts by 5-10 years

A

True

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5
Q

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

A

T

B; pannus

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6
Q

Imaging studies to order when RA is suspected

A

X-rays of hands and feet — detect symmetrical involvement of MCP/MTP joints; erosions

CT is more sensitive in detecting erosions!!

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7
Q

Treatment for RA that presents acutely

A

Begin NSAID for pain control

Early use of DMARD

May need low dose steroid for a few weeks

Monitor progress and toxicity

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8
Q

How does RA change during pregnancy?

A

Improves; then flares 4-6 weeks post partum

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9
Q

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?

A

CAD, CHF due to endothelial damage from chronic inflammation

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10
Q

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

A

Synovitis

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11
Q

What are the 4 class criteria utilized in the 2010 RA Classification Criteria?

A

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]

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12
Q

What lab values are used to monitor treatment response in RA?

A

Acute phase reactants (ESR, CRP)

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13
Q

What part of the spine is affected by RA?

A

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!]

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14
Q

T/F: RA pts have decreased risk of osteoporosis

A

False, they have increased risk

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15
Q

______ deviation of the wrist in RA in addition to synovial proliferation may lead to compression of the ____ nerve and subsequent carpal tunnel syndrome

A

Radial; median

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16
Q

Knee manifestations of RA

A

Bakers cyst — popliteal region

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17
Q

Diagnosis of RA typically requires active signs of inflammation of at least _________ duration

A

6 weeks

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18
Q

Complication of RA characterized by tender reddish purple papule; leads to necrotic, non-healing ulcer

A

Pyoderma gangrenosum

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19
Q

Purpura, petechiae, splinter hemorrhages, and digital infarcts are characteristic of rheumatoid ______

A

Vasculitis

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20
Q

T/F: Rheumatoid arthritis is an independent risk factor for CAD

A

True

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21
Q

_____ syndrome = nodular lung densities after exposure to coal or silica dust

A

Caplan

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22
Q

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?

A

Ro/SS-a, La/SS-b Abs

Schirmers test (litmus paper under eyelids to test for tear production)

Slit-lamp exam

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23
Q 
Rheumatoid arthritis
Splenomegaly
Thrombocytopenia
Neutropenia
Fever
Anemia
RF and anti-CCP positive
A

Felty’s syndrome

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24
Q

RA may be complicated by atlantoaxial subluxation (C1/C2) due to erosion of the _________ _______; other complications include peripheral neuropathy and ______ myelopathy

A

Odontoid process; cervical

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25
Q

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
A

I. All of the above

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26
Q

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

A

DMARDs

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27
Q

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

A

Folic acid

28
Q

Labs to monitor while pt is on MTX for RA

A

CBC
LFTs
Creatinine

Monitor q4-8 weeks

[toxicities include hepatic, myelosuppression, pulmonary]

29
Q

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?

A

Ophthalmologist d/t risk of macular damage to retina, blurred vision, halos, photophobic

30
Q

What RA drug?:

Pyrimidine antagonist
Rapid excretion with cholestyramine
Don’t use when pregnant
GI/hepatic toxicity/teratogenic

A

Leflunomide

31
Q

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?

A

WBC

32
Q

Toxicities of all biologics used in RA

A

Increased risk of infection

Reactivation of latent TB

Neoplasia

Multiple sclerosis

Autoimmune disease

33
Q

Pro-inflammatory cytokine in RA pathogenesis that stimulates synovial cell proliferation and collagenase

A

TNF-alpha

34
Q

Anti-TNF agents used in RA

A

Etanercept
Inflixumab
Adalimumab
Rituximab

35
Q

Overall management of RA

A

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

36
Q

Enteropathic arthritis and spondylitis develops in 20% of pts with either _____ or ______; this condition responds to treatment with ______

A

Crohns; UC; infliximab

37
Q

Clinical manifestations of spondyloarthropathies

A

Predilection for spine, SI joints

New bone formation at sites of inflammation

Joint ankylosis; fusion, rigidity, kyphosis

Asymmetric peripheral arthritis

Enthesitis

Ocular inflammation

38
Q

_______ = inflammation of insertion points of tendons and ligaments onto bones; component of spondyloarthropathies

Seronegative spondyloarthropathies may be related to immune susceptibility via allele _____

A

Enthesitis

HLA-B27

39
Q

______ = swelling of finger or toe; commonly seen in reactive arthritis/psoratic arthritis

A

Dactylitis

40
Q

Keratoderma is a skin manifestation of _______ arthritis

A

Reactive

41
Q

2 types of chronic polyarthritis with symmetric SI involvement and smooth, marginal syndesmophyte

A

Ankylosing spondylitis

Enteropathic arthrities

42
Q

2 types of chronic polyarthritis with asymmetric SI involvement and course, non-marginal syndesmophyte

A

Psoriatic arthritis

Reactive arthritis

43
Q

M:F ratio of RA, ankylosing spondylitis, enteropathic arthritis, psoriatic arthritis, and reactive arthritis

A

Rheumatoid — 1:3 (F)

AS — 3:1 (M)

EA — 1:1 (=)

PA — 1:1 (=)

Reactive — 10:1 (M)

[M:F]

44
Q

Eye manifestations of RA, ankylosing spondylitis, and reactive arthritis

A

Rheumatoid — scleritis

AS — iritis

Reactive — iritis and conjunctivitis

45
Q

Hallmark of spondyloarthropathy in children

A

Enthesitis — examples include plantar fasciitis, achilles tendonitis, costochondritis

46
Q

Not all pts with spondyloarthropathies are positive for HLA-B27. Which of the spondyloarthropathies is 90% positive for HLA-B27?

A

Ankylosing spondylitis

[reactive arthritis is positive 80% of the time, enteropathic spondylitis is 75%, psoriatic arthritis is 50%]

47
Q

What is the importance of asking if physical activity improves a young male pts’ SI joint pain?

A

If exercise makes it better, it is NOT DJD, and more likely to be AS

48
Q

Tests/imaging to order in a pt you suspect may have ankylosing spondylitis

A

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

49
Q

Most common inflammatory disorder of axial skeleton

A

Ankylosing spondylitis

50
Q

Clinical manifestations of ankylosing spondylitis

A

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

51
Q

Extra-articular manifestations of ankylosing spondylitis

A

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]

52
Q

2 special tests that may be performed on PE to identify ankylosing spondylitis

A

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

53
Q

ESR, CRP, HLA, CBC, RF, ACCP, and ANA results in ankylosing spondylitis

A

ESR and CRP increased

HLA-B27 positive in 90%

CBC shows Anemia of chronic disease

Negative RF, ACCP, ANA

54
Q

_______ = 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

A

Syndesmophytes

55
Q

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

A

DISH (diffuse idiopathic skeletal hyperosteosis)

56
Q

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

A

Osteitis condensans ilii

57
Q

Late complications of ankylosing spondylitis include _________ lung disease, _______ fractures, and __________ syndrome evidenced by bowel/bladder dysfunction and pelvis+low back pain

A

Restrictive; compression; cauda equina

58
Q

Treatment for ankylosing spondylitis

A

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

59
Q

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

A

Reactive arthritis

60
Q

Features of reiter’s syndrome/reactive arthritis

A

Urethritis
Arhtritis
Conjunctivitis (uveitis)

May also see mucocutaneous lesions (oral ulcers)

61
Q

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

A

Circunate balanitis

Keratoderma blennorrhagicum

62
Q

Reactive arthritis treatment

A

Usually self-limited (6 months)

NSAID, steroids (intraarticular)

If chronic progression, use DMARD (sulfasalazine, MTX, leflunomide)

Urethritis — if chlamydia, tx with azithromycin or doxycycline

63
Q

Pencil in cup deformity on x-ray

A

Psoriatic arthritis

64
Q

Treatment for psoriatic arthritis

A

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

65
Q

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

A

Large; small

Crohns disease

66
Q

Extraarticular manifestations of enteropathic arthritis/IBD-associated arthritis (skin, eyes, GI, GU, CV, bones)

A

Skin — pyoderma gangrenosum, erythema nodosum

Eyes — uveitis

GI — CD/UC

GU — nephrolithiasis

CV — thromboembolism

Bones — fracture, low bone density, vit D deficiency

67
Q

Treatment for enteropathic arthritis/IBD-associated arthritis

A

NSAID

Steroids — short relief

MTX/sulfasalazine

TNF-a inhib are effective for IBD arth

MSK II Exam II (10 decks)

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