Rheumatology Flashcards
What is RA
Systemic autoimmune disorder; multiorgan dz
Etiology of RA
Unknown
What class of joints affected
Diarthrodial
What part of joint affected
Synovial lining
What is pathognomonic for RA.
Erosions ; erosive synovitis > articular destruction
Composition of Diarthrodial joints (5)
- Type 2 hyaline 2. Subchondral bone 3. synovial membrane 4. Synovial fluid 5. Joint capsule
What is most important destructive element in RA?
Pannus
Pannus is a membrane of ______ tissue that covers the ______ bone & cartilage at joint margins
Granulation; articular
RA Female:male?
2:1
RA prevalence: what % of general pop?
1%
RA age range? Peak incidence?
20-60 . Prevalence rises with age. Peaks 4th- 5th
Decade
Etiology of RA is unknown. Name 3 theories
Environmental ie infectious; genetic predisposition; immunogenetic > class II surface antigen-presenting cells
RA diagnosis is made how?
Clinically
$How is RA diagnosed clinically? (3)
- Based on 1988 American Rheumatologic Association paper by Arnett et al ( current guidelines used by American College of Rheumatology (ACR) 2. Must satisfy 4/7 criteria
- Criteria 1 through 4 must be present for at least 6 weeks
$ Name ACR Criteria for RA (7)
AM Stiffness> Arthritis of 3 or more joints> Arthritis of the hand joints> Arthritis symmetric> rheum nodules > RF + > radio graphic changes
Review ACR details
1.Morning stiffness
•in and around hrs
•must last at least 1 hour before max improvement
2. Arthritis of 3 or more joints
•3 or more joint areas simultaneously affected with STS or
Fluid observed by doc
•14 possible joint areas are bilateral PIP, MCP, wrist, elbow, knee , ankle, & MTP’s
3. Arthritis of the hand joints
•At least 1 joint swollen in wrist, MCP, and/or PIP
4. Symmetric arthritis
• simultaneous involvement at the same joint area bilaterally
5. RHEUMATOID NODULES
• subqt nodules over extensor surfaces, bony prominences, juxta-articular regions, observed by a doc
6. Positive serum RF
7. Radio graphic changes
• erosions, bony decalcification, & symmetric joint-space narrowing seen on hand & wrist X-rays
$Compare/ contrast AM Stiffness in RA , OA, AS:
Joints, duration
Jts/ duration
MCP , PIP,MTP. > 1-2 hours: RA
DIP, < 30 mins
AS, LS spine , ~ 3 hours
$What’s most common onset of RA? Insidious, acute, intermediate
Insidious> 50-70%. Weeks to months. Systemic or articular
Acute >10-20%. Over several days. Less symmetry . Muscle pain
Intermediate> 20-30%. Over days to weeks
Systemic is more evident
What is lab test is definitive for RA?
No single test is definitive
name typical lab findings in active dz
RF, Elevated acute phase reactants( ESR, CRP),CBC: | platelets! hypo, micro anemia , eosinophilia, synovial fluid , ab to CCP, hypergammaglobulinemia, hypocomplementia
$ synovial fluid in RA: viscosity, WBC, PMN’s, appearance
Low, 1-75 K WBC’s/mm3 (> 70% PMN’s), transparent - cloudy
% of patients with RA Who are RF +?
85%
Radio graphic findings in RA
- Early Findings (2)
- Late Findings (3)
- characteristic findings
Joints commonly involved in RA
Hands & wrists
Cervical spine – C1 to C2
Feet & ankles
Hip & knees
Describe/ Name UE Joint deformities
BOUTONNIÈRE SWAN NECK ULNAR DEVIATION OF FINGERS TENOSYNOVITIS CARPAL BONE INSTABILITY ULNAR HEAD FLOATING RESORPTIVE ARTHROPATHY PSEUDOBENEDICTION SIGN SHOULDER ELBOW
Describe cervical spine concerns in RA
Atlantiaxial joint subluxation
What’s most common? Ant or post
Ans. anterior
$ with cervical flexion, the atlanto-axial space should not increase sig.
Any space larger than _____ is
Considered abnormal
2.5-3mm
Hip deformities
Occur in what 50% of RA Patients?
What is protrusio acetabuli?
50%
Associated with hip arthritis
Inward bulging of acetabulum into pelvic cavity;
Extra-articular manifestations of RA
Constitutional Skin Vasculitic Ocular Pulmonary Cardiac--- see pericarditis card GI Renal Neuro Hematologic
Extra-articular manifestations of RA
Delineate
Xxxx
Subqt nodules are seen in ? (2)
Gout
RA
What is Caplan’s Syndrome ? (4)
• associated with RA and pneumoconiosis in coal workers
• Granulomatosis response to silica dust
• +RF
Intrapulmonary nodules– histologically similar to Rheumatoid Nodules
What are cardiac findings assoc with RA?
Pericarditis $ classic findings • chest pain • pericardial friction rub • EKG abnormalities ( diffuse ST elevations)
Pericarditis assoc with RA may lead
Constrictive pericarditis with ?
May be found in ____ of RA Patients
How often symptomatic?
Right-sided heart failure
Half
Rarely
In addition to pericarditis, what other cardiac finding is associated with RA ?
Valvular heart dz
$ What is Feltys syndrome ?
Classic triad of:
RA
Splenomegaly
Leukopenia
Feltys syndrome Seen in \_\_\_\_\_\_\_RA with \_\_\_\_\_ Occurs in what decade of life? Duration of RA? Gender Assoc with \_\_\_\_\_\_ ulcers
Seropositive; nodules 5th or 7th > 10 years Women comprise 2/3 cases Leg
Treatment of RA (6)
Education Rest Physical modalities Orthotics Meds Surgery
Poor prognosticators (6):
\+RF Rheumatoid nodules X-ray consistent with erosive dz Persistent synovitis Insidious Antibodies to CCP ( cyclic citrullinated peptides)
Important determinants in classifying arthritis:
Inflammatory vs non-inflammatory
Symmetric vs asymmetric
Accompanied by systemic & extra articular manifestations
ARTHRITIC DZ
What 3 items will often lead to a specific dx?
Good H&P
Appropriate labs
Appropriate X-rays
Clinical features that suggest inflammatory dz:
Acute painful onset
Erythema overlying skin of joint
Warmth of joint(s)
Tenderness usually commensurate
The degree of inflammationLab & X-ray findings that suggest
An inflammatory process (4)
Increased WBC with left shift
Increased ESR
Group II joint fluid
X-ray : STS, periostitis, bony erosions or uniform cartilage loss
Inflammatory Arthritis may fall into 4 different groups. It may be mono or poly articular
Name/Describe
- Inflammatory CT
- Inflammatory Crystal-induced
- Inflammatory induced by infectious agents (e.g. Bacterial, viral, spirochete , tuberculosis , fungal
- Seronegative spondyloarthropathies
Non inflammatory arthritis may be classified as? (2)
Degenerative
Metabolic ie lipid storage , hemochromatosis , ochrinosis, etc
Many types of arthritis have a specific distribution in terms of ?
Name 4.
Name two other potential influencing factors
Age, gender, race , geographic appearance
Genetics and occupation
RA & Medications
One of the main goals of pharmacotherapy in RA is to
________ systemic inflammation & consequently _________ joint erosions and deformities
Reduce
Name the commonly used medications (3) hint: Name the three
Groups and examples
Non-DMARDS
NDAIDS
Glucocorticoids
DMARDS – mainstay of RA pharmacotherapy
Biologicals
Non-Biologicals
Surgical intervention in RA (5)
Surgical fusion of c1-2 for atlantoaxial instability
Synovectomy: most commonly?
Arthroplasty: most common?
Arthrodesis: typically for ?
Tendon repairs: successful?
Synovectomy: most commonly? Arthroplasty: most common? Arthrodesis: typically for ? Tendon repairs: successful? (RA)
Synovectomy: most commonly with
Extensor tenosynovitis at wrist
Arthroplasty: most commonly of knee and hip; shoulder, MCP infrequent; elbow rare
Arthrodesis: typically for ankle, occ for wrist or thumb
Tendon repairs: generally successful; most hand/wrist tendinopathies require tendon transfer
Name non bio DMARDS (8)
Least to very toxic
Sulfasalazine-- safer MTX --- safer Cyclosporine Gold, IM/oral Azathioprine D-penicillamine Chlorambucil--- very toxic Cyclophosphamide ---very toxic
Name 4 categories of bio DMARDS
Anti-tumor necrosis factor (Anti-TNF) agents: reduce levels of TNF-alpha
Co-stimulation Modulators: prevent T-cell activation by interfering with antigen-presenting cell interaction with T cells
Anti-B-cell antibodies
Depletes B-cells
Interleukin Antagonists
Antagonizes IL-1 by binding to interleukin receptors
Other drugs for RA
ASA
NSAIDS
Corticosteroids
ASA
NSAIDS
Common side effects(4):
GI Ulceration & bleeding
Renal insufficiency
Hepatic inflammation
HTN
Corticosteroids
Side effects
Hyperglycemia Inhibits immune response Osteoporosis PUDZ Emotional lability
Anti-TNF Alpha Agent examples (3)
Etanercept ( Enbrel) = soluble receptor
Infliximab ( Remicade)= chimeric antibody
Adalimumab (Humira)= human monoclonal antibody
Co-stimulation Modulators
Give an example
Abatacept (Orencia)
Anti-B-cell antibodies
Example
Rituximab
Interleukin Antagonists
Name one
Anakinra (Kineret)
What is ASA therapeutic level?
Greater than ? Is toxic.
15-25 mg/DL ; 30
