Rheumatology Flashcards
what is the definition of rheumatoid arthritis?
symmetrical polyarthritis of small joints
which joints are most commonly affected by RA?
metacarpophalangeal (MCP)
proximal interphalangeal (PIP)
metatarsophalangeal (MTP)
which gender is most likely to present with RA, and how much more likely?
females 3x more likely than males
what age does RA commonly present?
40s/50s
what is the main genetic factor involved in RA?
changes in HLA-DRB1
what is the genetic evidence of RA?
twins up to 30% more likely to both have RA compared to general population
what is the main biochemical trigger to the immune cascade in RA?
presence of citrullinated proteins in the joint
which cytokines involved in RA are released by T-cells?
Interferon Gamma
Interleukin 17
what cytokines involved in RA are released by macrophages in the synovium?
Interleukin-6
TNF-alpha
what process causes bone destruction in RA?
T-cell activating osteoclasts by triggering RANKL cascade
what is Rheumatoid Factor?
it’s an IgM antibody that binds to the FC portion of IgG
what are the four main physiological features of RA in a joint?
- pannus (eg thickened synovium)
- inflammatory infiltration
- neoangiogenesis
- cartilage/bone destruction
what are the common symptoms of RA?
- pain
- stiffness
- loss of function
- immobility
- systemic symptoms (fever, malaise, loss of appetite, nodules, SoB from fibrosis)
what are the common signs of RA?
- symmetrical joint presentation
- synovitis
- swelling
- tenderness
- heat
- redness
what investigations should be carried out to diagnose RA?
- blood test for RF and anti-CCP
- xray of joint
- ultrasound of joint
what are the medical treatment options for RA?
- NSAIDS
- DMARDS
- biologics
- corticosteroids
which three DMARDS are most commonly used in RA?
- methotrexate
- hydroxychloroquine
- sulfasalazine
name a few biologic treatments for RA and what they target
- rituximab (B cells)
- abatacept (T cells)
- infliximab/adalimumab/etanercept (TNF-alpha)
- anakinra (IL-1)
- tocilizumab (IL-6)
what is a recognised benefit of dual therapy of biologics + methotrexate in RA?
enhanced response to drug
what process leads to cartilage destruction in RA?
production of proteases by fibroblast-like synoviocytes (FLS)
which two main autoantibodies are associated with RA?
- rheumatoid factor
- anti-citrullinated peptide antibodies (ACPA)
give a few examples of the proteins which may undergo citrullination in RA, resulting in an inflammatory cascade
- type 2 collagen
- vimentin
- fibrinogen
- fibronectin
- alpha enolase
- keratin
what is the main downside to prescribing methotrexate for RA?
it’s teratogenic (anti-folate)
what is meant by the term seronegative arthritis?
a type of arthritis with negative result for Rheumatoid Factor
which gene are seronegative arthritides commonly associated with?
HLA-B27
which two criteria are used to diagnose ankylosing spondylitis?
> 3month back pain, <45yo plus either:
- sacroiliitis on imaging + 1 AS feature
- HLA-B27 + 2 AS features
name a few features of ankylosing spondylitis
- persistent back pain
- reduced axial skeleton movement
- reduced chest expansion
- dactylitis
- enthesitis
- arthritis
- uveitis
- IBD (crohn’s, ulcerative colitis)
- sacroiliitis/spondylophytes on imaging
- good response to NSAIDS
- HLA-B27
- seronegative
- elevated CRP
name the management options for ankylosing spondylitis
- physiotherapy
- NSAIDS
- DMARDs
- biologics
- surgery (joint replacement)
which triad of symptoms is common in reactive arthritis, and what is it called?
Reiter's syndrome, triad of: - arthritis - urethritis - conjunctivitis "can't see, can't pee, can't climb a tree"
name a few common pathogens which may cause reactive arthritis
chlamydia trichomatis neisseria shigella salmonella campylobacter streptococci
how can ankylosing spondylitis present in different systems?
heart - aortic regurgitation, heart block lungs - pulmonary fibrosis GI - IBD (crohn's, UC) kidneys - secondary amyloidosis nervous system - cauda equina syndrome skeletal - osteoporosis/fractures
what feature of psoriatic arthritis can be seen on xray imaging?
pencil in cup deformity
what feature of psoriatic arthritis can be visible in patients’ nails?
nail pitting
name some features of reactive arthritis
keratoderma blenorrhagica balanitis uveitis iritis conjunctivitis urethritis arthritis of big joints
how is reactive arthritis treated acutely and chronically?
acute - NSAIDS, antibiotics if needed, joint injection if no infection
chronic - NSAIDS and DMARDs
what are the management options for psoriatic arthritis?
physiotherapy NSAIDs DMARDs biologics occupational therapy corticosteroids
which patient population is more likely to develop ankylosing spondylitis?
males in 20s/30s
which symptom (including duration and age) is often key in seronegative arthritis?
inflammatory back pain, longer than 3 months in patients younger than 45
which seronegative arthritis is not normally treated with a trial of NSAIDs?
enteropathic arthritis
what types of infection normally cause reactive arthritis?
GI infections
genitourinary tract infections
throat infections
what specific symptom associated with reactive arthritis can present on the skin?
keratoderma blennorrhagica
what is enteropathic arthritis?
arthritis associated with underlying IBD
what are the criteria for diagnosing juvenile idiopathic arthritis?
- symptoms for >6 weeks
- age of patient <16
- 2+ inflammatory features in joint
what are the three main subsets of juvenile idiopathic arthritis? what defines them?
pauciarthritis - less than 4 joints affected
polyarthritis - more than 5 joints affected
systemic - other systems affected before arthritis sets in
what specific eye condition is commonly associated with juvenile idiopathic arthritis?
anterior uveitis
how many subtypes of pauciarticular JIA are there?
3 types
how is polyarticular JIA subclassified?
RF+ve and RF-ve polyarticular JIA
which type of pauciarticular JIA is associated with younger age, involvement of LL joints and more commonly in girls?
Type 1 pauciarticular JIA
what characterises Type 2 pauciarticular JIA?
age 8/9
boys>girls
hips more commonly affected, sometimes severely
which type of pauciarticular JIA presents with similar involvement of UL and LL joints but also dactylitis and psoriasis?
Type 3 pauciarticular JIA
which type of JIA doesn’t normally present with systemic symptoms?
pauciarticular JIA
which type of JIA can present with low grade fever and malaise?
polyarticular
name a few symptoms which can differentiate systemic JIA from the other subtypes
high fever
salmon rash
hepatosplenomegaly
lymphadenopathy
what are the management options for JIA?
- painkillers
- NSAIDS
- DMARDS (methotrexate)
- biologics (anti-TNF, anti IL-1 and anti IL-6)
- physiotherapy/occupational therapy
- surgery (synovectomy, joint replacement)
when are systemic steroids used for JIA?
sometimes used for severe systemic JIA or to treat serious complications
what are the effects of JIA on development?
- uneven digit/limb length
- underdeveloped jaw
- short stature
- delayed puberty
why is it sometimes difficult to diagnose systemic JIA?
because the main features (high fever and rash) can come and go very quickly, so they can be hard to spot
which subtype of JIA is the most common?
pauciarticular JIA
what is the prevalence of RA?
1% of population
what is the difference between spondyloarthropathies and rheumatoid arthritis in terms of joint involvement?
RA tends to affect the small peripheral joints; spondyloarthropathies normally affect axial joints (spine, sacroiliac joint)
what is the acute management of reactive arthritis?
NSAIDS
steroid injection
antibiotics
what is the chronic management of reactive arthritis?
NSAIDS
DMARDs
which type of crystals are involved in pseudogout and where do they build up respectively?
pyrophosphate crystals in joints
apatite crystals in tendons
which type of crystals are involved in gout?
urate crystals
what is a useful diagnostic indicator of whether stiffness is due to osteoarthritis or rheumatoid arthritis? explain the difference
duration of stiffness and pain in the morning
- in RA, pain lasts longer than 30 mins
- in OA, pain lasts less than 30 mins
what are three factors which are thought to lead to osteoarthritis?
- damage
- inflammation
- repair
what are the main symptoms of osteoarthritis?
pain
loss of function
short-lived morning stiffness
name a few signs that can be seen in an osteoarthritic joint xray
- loss of joint space
- osteophytes
- subchondral sclerosis
name a few non-pharmacological treatments for osteoarthritis
mechanical aids
heat packs
electrotherapy
physiotherapy
name a few pharmacological treatments for osteoarthritis
NSAIDS/paracetamol
hyaluronic acid injections
steroid injections
what is the surgical option for osteoarthritis?
partial or total joint replacement
when is surgery considered for patients with osteoarthritis?
when disease is affecting QoL
if non-surgical options have failed
what are the three key features to diagnose osteoarthritis?
over 45
activity-related joint pain
no morning stiffness/less than 30mins
