Rheumatology Flashcards
Common symptoms people present to rheumatology with
pain stiffness swelling functional impairment systemic symptoms
Signs of RA
tenderness swelling restricted movements heat and redness systemic features
List some rheumatic diseases
RA connective tissue diseases sero negative arthritis bone disease crystal arthritis systemic vasculitis
Functions of synovium
maintain intact tissue surface
lubrication of cartilage
control of synovial fluid volume and composition - hyaluronic acid and lubricin
nutrition of chondrocytes within joints
Describe the rheumatoid joint
inflamed synovium and tendon sheath
erosion into corner of the bone and thinning of cartilage
Define RA
chronic, symmetric, autoimmune, inflammatory
small joints in hands and feet
pannus
rheumatoid synovitis
inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis
What is found in synovial fluid in acute RA flares?
neutrophils
Autoantibodies
RF and ACPA
What can the autoantibodies recognise?
joint eg type 2 collagen or systemic antigens
How can autoantibodies contribute to inflammation?
activation of complement
What does RF do?
autoantibody to self IgG Fc
does sero negative or positive RA have a better prognosis?
negative
Genes in RA
susceptibility and severity
monozygotic twins: 15-30%
HLA-DR4, PTPN22
promote autoimmunity and molecular mimicry
Environmental factors
smoking and bronchial stress
infectious agents eg viruses and periodontal disease
What happens after repeated insults in a susceptible person?
form immune complexes and RF
altered citrullination of proteins and breakdown of tolerance with resulting ACPA response
citrullination
converting the amino acid arginine to citrulline
Very briefly describe the synovitis with inflammatory cells
CD4+ T cells, macrophages and B cells
local hypoxia and cytokines –> neoangiogenesis
insufficient lymphangiogenesis for clearance
What T cell cytokines do Th1 and 17 produce?
IFN- alpha and IL-17
What are ectopic lymphoid follicles?
synovial B cells mainly in Tcell-B cell aggregates
What produce chemokines?
macrophages and fibroblasts
IL-6 systemic effects
acute phase response
anaemia
cognitive dysfunction
lipid metabolism dysregulation
Purpose of neoangiogenesis in RA
provide nutrients to hyperplastic synovium
Why does neoangiogenesis occur?
hypoxic conditions and angiogenic factors eg IL-8, VEGF
What produces metalloproteinases and aggrecanases and what do these proteases do?
fibroblasts
can attach and invade cartilage
What activates osteoclasts and where is it produced?
RANKL
synovium
Systemic consequences of RA
vasculitis, nodules, scleritis, amyloidis
CVD
fatigue and reduced cognitive function
liver, lungs - fibrosis, ILD
sarcopenia, osteoporosis, sjogrens syndrome
List some classification criteria for RA
morning stiffness for atleast 1 hour arthritis of more than 3 joints, hand joints symmetric nodules serum RF radiology changes
Most commonly affected people with RA
women, 1%, can happen anytime after 16 but usually in 4th or 5th decade
Immunology for RA
anti CCP, ACPA
RF - IgG, IgM
investigations for RA
x-rays
doppler USS
symptoms of RA
pain, stiffness, immobility, poor function, systemic symptoms
signs of RA
swelling - tenderness - heat - red - limited movement
non specific systemic features
fatigue, weight loss and anaemia
Specific systemic symptoms
eyes, lungs, nerves, skin and kidneys
long term features
CVS and malignancy
What does the disease activity score help determine?
time for biologics or if in remission
Therapies for RA
NSAIDS, DMARD, biologics, steroids
DMARD in use
methotrexate and hydroxychloroquine
positives of methotrexate
cheap - well tolerated - effective - combination treatment - well concordance
treatment strategies
monotherapy (sequential)
combination: step up, step down, parallel
treat to target
briefly describe pros and cons of biologics
target inflammatory cascade, work rapidly ad well tolerated
toxic, expensive, infections, malignancy
name some biologics
TNF alpha inhibitors
Anti B and T cell therapies
IL6 inhibitors
how can CCS be given?
im, ia, IV
Are CCS appropriate for monotherapy?
no
MDT for RA
orthotics podiatrist rheumatology specialist nurse rheumatology physio rheumatology OT pharmacist clinical psychologist
3 assessments when starting biologics
TB scar/chest X-ray
chronic blood borne viral screen
VZV serology
