Rheumatology Flashcards
If suspect RA on a hand exam, what else to examine?
- Other joints including C spine
- Blood pressure (overall CV risk)
- Extra-articular manifestations of disease
- Face: conjunctival pallor for anemia, eyes (Sjogren’s)
- Lungs: fibrosis (RA-ILD, MTX-ILD), pleural effusions, Caplan’s syndrome / rheumatoid pneumoconiosis (nodular condition in RA when exposed to dust)
- Heart: pericardial rubs (pericarditis)
- Abdomen - splenomegaly (Felty’s), HSM (RA is a/w increased risk of lymphoma), injection sites (biologics)
- Lower limbs - pyoderma gangrenosum, neuropathy, feet
Who gets rheumatoid nodules in RA?
And where are rheumatoid nodules, typically?
Rh factor +ve patients only
(Nothing to do with CCP)
Elbows (but can be anywhere)
What are the lung manifestations of RA?
- ILD
- Usually UIP
- Pleural effusion
- Exudative (high protein, LDH)
- Low glucose (<2.2, rule out empyema & malignancy)
- pH < 7.2 (rule out empyema, oesophageal rupture)
- Lung nodules
Which single autoantibody is most specific for RA?
Which is more sensitive?
Anti-CCP / ACPA (specificity 95%)
RhF is more sensitive (but only 70%)
What are markers of poor prognosis in RA?
Early erosions on XR (the strongest)
RhF / Anti CCP
HIgh levels of inflammation (ESR and CRP)
HLA DRB1*04
Smoking
Extra articular features
Alfred lecture also said: high number of swollen and tender joints, functional limitation
What is this?
Remitting, seronegative, symmetric synovitis with pitting edema (RS3PE)
An atypical presentation of RA
A tenosynovitis
Might be a paraneoplastic pheneomenon
Very good response to low dose glucocorticoids
What are the features of OA on XR?
L: loss of joint space
O: osteophytes
S: subchondral cysts
- can be mistaken as erosions
S: subchondral sclerosis
- NB in RA there is periarticular osteopenia
What is the cause of this?
Psoriatic artthritis
- Pencil in cup deformity
- Ankylosis
- Subluxation
- Periostitis
- Absence of periarticular osteopenia (differentiates from RA)
- Arthritis mutilans
- Hand joint involvement:
- DIP, PIP
- Other joints:
- Feet, sacroiliac, spine
- Knee, elbow, ankles, shoulders much less common
Remember: tends to effect ‘ray’ not ‘row’ in PsA
What is the cause of this?
Rheumatoid arthritis
- Soft tissue swelling
- Juxta-articular osteopenia
- Joint space narrowing
- Marginal erosions
- Subchondral cysts
- Subluxation and deformity - ulnar deviation MCP, boutonniere and swan neck, hitchhiker thumb
- Hand joint involvement:
- PIP and MCP (esp. MCP 2-3)
- Ulnar styloid
- Triquetrum
- DIP spared
- Other joints:
- Feet (PIP, MTP esp 4-5)
- Shoulder, hip, knee, C-spine
What are the causes of a positive rheumatoid factor?
- SLE (~30%)
- Sjogren’s (<100%)
- Scleroderms (30%)
- MCTD (50%)
- Mixed cryoglobulinemia (100%)
- Certain infections (malaria, rubella, Hep C, TB)
- Malignancy
- Healthy subjects (5-10%)
Can you use RhF or anti-CCP to monitor disease activity in RA?
No
What is palindromic rheumatism?
Atypical presentation of RA
- Articular or sometimes periarticular pain, then swelling and erythema
- Symptoms worsen for hours to a few days
- Symptoms resolve in reverse sequence (think palindrome) with no residua
- 50% will go on to develop RA - ACPA +vity helpful in predicting
Treatment: hydroxychloroquine (may reduce risk of progression to RA)
Who tends to get nodal generalised osteoarthritis?
post-menopausal females
usually have female family history of same
- Compare the XR findings, specifically:*
- -erosions*
- joint space*
- bone density*
- in:*
Gout
RA
PsA
Gout
Punched out erosions, joint space preservation, tophi
RA
Juxta articular cortical erosions, joint space narrowing, osteopenia
Psoriatic arthritis
Pencil in cup, bony proloferation / periostitis, DIPJ involvement
What tests would you like to order if you suspect RA?
- FBE (anaemia related to disease e.g. chronic disease / Felty’s or related to treatment eg bleeding due to NSAIDs / steroids, folate deficiency / cytopenia related to MTX)
- ESR / CRP
- RhF (not specific, do NOT monitor for disease activity)
- Anti-CCP (specific, do NOT monitor for disease activity)
- Hand XR
Other / wholistic tests
- Imaging of the other joints including lateral C spine XR to rule out atlanto-axial subluxation
- CXR /CT chest if suspect ILD / effusions / Caplan’s syndrome / nodules
- TTE if suspect pericarditis
- Lipids / HbA1c for CV risk
- Vitamin D / calcium / DEXA if suspect OP (due to treatment / steroid exposure or RA on its own)
What are the causes of a symmetrical, deforming polyarthopathy?
- Rheumatoid arthritis
- Psoriatic arthritis or enteropathic arthritis (other spondyloarthopathies eg. reactive arthritis tend to cause a mono arthritis)
- Osteoarthritis [although usually asymmetrical or a mono/oligo arthritis]
- Polyarticular gout / chronic tophaceous gout [although gout / CPDD usually asymmetrical or a mono/oligo arthritis]
- Jaccoud’s arthropathy of SLE
- ??Systemic sclerosis
What is the features of gout on synovial fluid analysis?
What is the features of pseudogout on synovial fluid anlaysis?
The true purist would say you need to see intracellular (intra-neutrophil) crystals; you can see uric acid crystals in a joint with OA!
- Monosodium urate (gout)
- Brightly, negatively birefringent in polarized light, needle-shaped
- Negatively birefringent = turn yellow when aligned parallel to the light source, turn blue when perpendicular
can remember: yeLLow when paraLLel
- Calcium pyrophosphate dehydrate (pseudogout)
- Weakly, positively birefringent, rhomboid or rectangular
- Positively birefringent = turn blue when aligned parallel to the light source, turn yellow when perpendicular
On synovial fluid analysis, what WCC is typical of a non-inflammatory cause of an arthopathy?
200 - 2,000
On synovial fluid analysis, what WCC is typical of an inflammatory cause of an arthopathy?
2,000
to
50,000 - 100,000
On synovial fluid analysis, what WCC is typical of an infective cause of an arthopathy?
> 50,000
Colour changes in Raynauds
White then blue then red
