Rheumatology

Question 1

Definition of arthritis

Answer 1

Inflammation of a joint/joints

Question 2

Presentation of arthritis

Answer 2

pain 
stiffness
swelling
functional impairment 
systemic symptoms
tenderness 
swelling 
restriction of movement 
heat
redness

Question 3

Types of drugs used to treat RA

Answer 3

NSAIDs
DMARD - disease modifying anti-rheumatic drug
Biologics
Corticosteriods

Question 4

An example of a DMARD

Answer 4

Methotrexate

Question 5

What do DMARDs do in RA?

Answer 5

Slow onset effect of disease activity and retard disease progression

Question 6

What do biologic DMARDs do in RA?

Answer 6

target key aspects of the inflammatory cascade

Question 7

Examples of biologics

Answer 7

TNFa inhibitors
IL-1 inhibitors
Anti B cell therapies

Question 8

Definition of RA

Answer 8

A chronic autoimmune systemic illness characterised by a symmetrical peripheral arthritis and other systemic features

Question 9

Which gender is RA more prevalent in?

Answer 9

F > M, 3:1

Question 10

Age of onset of RA

Answer 10

Peak age 4th/5th decade

May occur at any age > 16

Question 11

Causes of RA

Answer 11

Genetic (50-60%)
Cigarette smoking
Chronic infection e.g. periodontal disease

Question 12

Pathology of RA

Answer 12

Inflamed synovial membrane
cartilage thinning
neutrophils main cell type in synovial fluid
pannus
- major cell types; T lymphocytes and macrophages
- minor cell types; fibroblasts, plasma cells, endothelium, dendritic cells

Question 13

Investigations of RA

Answer 13

Rheumatoid factor
- IgG
- IgM
Anticyclic citrullinated antibodies 
- Anti CCP
- ACPA

Question 14

Symptoms/signs of RA

Answer 14

pain 
stiffness (including morning stiffness)
immobility 
poor function 
systemic symptoms 
swelling
tenderness 
limitation of movement
redness
heat 
rheumatoid nodules 
Fatigue/lassitude 
weight loss
anaemia
effects on eyes, lungs, nerves, skin, kidneys
long term - CVS, malignancy

Question 15

ARA criteria for RA

Answer 15

1. morning stiffness
2. arthritis of 3 or more joints
3. arthritis of hand joints
4. symmetric arthritis
5. rheumatoid nodules
6. serum rheumatoid factor
7. radiographic changes

Question 16

Disease activity score of RA

Answer 16

DAS < 2.4 = clinical remission

DAS > 5.1 = eligibility for biologic therapy

Question 17

What does rheumatoid factor do?

Answer 17

A circulating antibody (usually IgM) which reacts with the Fc portion of the patients own IgG

Question 18

How can rheumatoid factor be identified?

Answer 18

Rose-Waaler test; sheep red cell agglutination

Latex agglutination test (less specific)

Question 19

What % of patients with rheumatoid arthritis have +ve RF?

Answer 19

70 - 80%

Question 20

Other conditions with +ve RF

Answer 20

Sjogrens (100%)
Feltys syndrome (100%)
IE (50%)
SLE (20-30%)
Systemic sclerosis (30%)
General population - 5%
Rarely - TB, HBV, EBV, Leprosy

Question 21

What other antibody can be detected in RA?

Answer 21

Anti cyclic citrullinated peptide antibody (ACCPA)

Question 22

When can ACCPA be detectable?

Answer 22

Up to 10 years before the development of RA

Question 23

Which HLA allele is associated with RA?

Answer 23

HLA-DR4

Question 24

S/Es of hydroychloroquine

Answer 24

Retinopathy

Corneal deposits

Question 25

What predisposes a patient to azathioprine toxicity? What must be done before starting treatment?

Answer 25

Thiopurine methyltransferase deficiency

Check for the deficiency before treatment

Question 26

Relationship between HLA-B27 and reactive arthritis

Answer 26

HLA-B27 predisposes to recurrent reactive arthritis and hence should take extra care to avoid infections e.g. chlamydia which cause these recurrences