Rheumatology - Told Flashcards
osteoarthritis
not inflammatory
pain
dalor
heat
calor
rubor
redness
swelling
tumor
cardinal features of inflammation
dalor, calor, rubor, tumor
also - tenderness, stiffness, crepitation
single joint
monoarthritis
2-4 joints
oligoarthritis
<5 joints
pauci
5 or 6 joints
extended pauci
> 6 joints
poly arthritis
insertion of tendon
enthesis
ESR
non protein acute phase reactant - effects plasma viscosity as fibrinogen is consumed
more inflammation - less viscous plasma - more cells fall out of suspension
time course of rheumatoid arthritis
10 years from initial immune stirring to disease onset
initial immune stirring - RF, anti-CCP, and elevated CRP
rheumatoid factor
auto-Abs - usually IgM
complement consumption
in RA joint
immunopathology of RA
rheumatoid factor produced by synovium
- RF fixes complement
- complement consumed
- recruit and activates PMNs
- localized immune complex disease
TNF and MAC destroy joint
pro-inflammatory
TNF-a and IL-1
anti-inflammatory
soluble TNF receptor
IL-1 antagonist
epidemiology of RA
more in women
1-2% of population
peak age 25-45yo
improves during pregnancy
rheumatoid arthritis
associated with RA
infection renal disease GI disease heart disease - recently has gone down malignancfy
diagnosis of RA
4 criteria met
1 - morning stiffness >1 hour* 2 - swelling 3 or more joint areas* 3 - swelling in hand joints* 4 - symmetric joint swelling* 5 - rheumatoid nodules 6 - rheumatoid factor 7 - erosion or osteopenia on hand x-ray 8 - must be present >6 weeks *longer than 6 months
PIP
rheumatoid arthritis
DIP
osteoarthritis
pannus
infiltrating lymphocytes - seen in rheumatoid arthritis
ulnar deviation
rheumatoid arthritis
U/S vs. RA
inflammation better seen with ultrasound**
imaging in RA
X-ray insensitive
MRI - occult erosions, synovial enhancement, synovial thickening
boutonniere deformity
in hand with RA
enthesitis and rupture
swan neck deformity
in hand with RA
enthesitis and rupture
enthesitis
inflammation where tendon/ligament insert into bone
rheumatic nodules
almost pathognomonic of RA
-always RF positive
additional mainfestations of RA
rheumatoid nodules sjogrens feltys vasculitis rheumatoid lung cardiac neuromyopathy inflammatory eye disease** osteoporosis lymphadenopathy hyperviscosity - DVT cryoglobulinemia dermatologic amyloidosis
myelopathy in RA
spinal cord damage
-no HVLA**
neck pain radiates to occiput dysesthesia of fingers and feet marble sensation - limbs and trunk jumping leg disturbed bladder function
scleritis and scleromalacia
seen with RA
-inflammatory eye disease
sicca symptoms
dry eyes, dry mouth, vaginal dryness, tracheo-bronchial dryness
sjogrens - can occur with rheumatoid arthritis
SS-A
Ro
SS-B
La
SS-A and SS-B
Ro and La
associatd with primary sjogrens
Rh + anti-CCP + ANA + ESR/CRP elevated anemia thrombocytosis hyperglobulinemia leukopenia/granulocytopenia glucose in body fluids - very low
seen in RA
diagnosis of RA based on auto-Abs
RF alone - needs to be very high for diagnosis - not that specific
with anti-CCP - increased specificity
CCP
cyclic cirtullinated protein
good predictor of erosiveness
RF
anti-CCP alone
96% specific
anti-CCP and RF
98% specific
goal of therapy in RA
alleviate pain
slow rate of joint damage
only things we can do unfortunately
pharmacotherapy for RA
NSAIDs - toxicity assocation corticosteroids - chronic use - bad DMARD - delayed onset of action biologic - infection and \$\$$ analgesic - long last opiod - control pain and improve function
DMARDs
methotrexate
leflunomide
also hydroxychloroquine, sulfasalazin, gold compounds, azathioprine, cyclosporine
category X in pregnancy
leflunomide and methotrexate
IL-1 receptor antagonist
anakinra
soluble TNF receptor
etanercept
anti TNF-a Abs
adalimumab
infliximab
once a week dosing
methotrexate
early onset of action
leflunomide
rapid exretion with cholestyramine
leflunomide
goal of tx with RA
AM stiffness 5 criteria must be met >2 consecutive months
co-morbid disease in RA
lung and eyes
low dose steroids
for flares of RA
biologic agent
only if non-biologics fail
