Rhuem Flashcards
Define RA and explain pathophysiology
INFLAMMATORY SYNOVITIS
autoantibodies attack host
Neutrophils and T cells in the synovial fluid cells are activated
Cytokines, Interleukin-1, TNF-alpha, Chondrocytes all attack cartilage.
Synovium then digests cartilage, inflammatory molecules released containing interleukin-1 and TNF alpha
shared epitope in RA (HLA___?)
HLA BRB1
epidemiology of RA
FM 3:1
>15 y/old
more common in smokers
what areas does RA spare?
Lower back
DIP
WHat is a Pannus?
abnormal tissue growth cause by thickening or inflammation of the synovium.
Cytokines cause new blood vessels to develop in the synovium causing growth of extra tissues eventually forms pannus
what is a characteristic of RA seen on Physical exam and where would these be found?
Nodules
seen on
hands
olecranon
Calcaneal tuberosity
2 deformities seen in RA
Boutonniere deformity: flexion of the PIP and hyperextension of the DIP joint.
Swan neck deformity: hyperextension of the PIP and flexion of the DIP joint.
What would you see on a blood test in pts w/ RA
Hypochromatic-microcytic anemia with low serum Fe
or normal iron-binding capacity almost universal in patients with active RA
what would you find on Physical exam in a pt with RA
Warm tender erythematous joints, hands and wrists
DIP are notably excluded
Ulnar Deviation of the digits
Boutonniere’s deformity
Rheumatoid Nodules
Cysts in popliteal space (Baker’s cyst)
Decrease ROM in joints
What antibodies are usually positive in pts w/ RA
Anti-CCP
ANA (20%)
RF (although does not rule out RA if negative)
what are 2 subtypes of RA
ACPA + is a more aggressive clinical phenotype (67%)
responds better to tx
ACPA - respond less to common treatments
how many points id dx for RA
6 points
first line tx for RA
DMARD
methotrexate
Leflunomide ( alt to methotrexate high GI side affects)
what do you prescribe pts w/ RA while waiting for DMARDs to take effect
corticosteroids (prednisone) for flares
NSAIDs
COX-2
complications seen w/ RA
feltys synd
baker cyst
carpal tunnel
altanto-axial subluxation
what is felty’s synd
Triad of RA + Neutropenia + Splenomegaly
complication of RA - tx RA and this should resolve
what is Polymyalgia Rheumatica (PMR)
inflammatory disorder of pain associated with the proximal muscles
seen in elderly, more common in white women
HIGH correlation w/ GCA
key feature of PMR
key feature is pain and not weakness, strength is IN TACT
Symptoms worse in AM
Does not cause swollen joints
Patient describes general aches and pains, stiffness, especially upper arms, thighs, hip girdle and shoulders. “trouble getting dressed”
Dx????
PMR
Gold standard Dx of PMR
ESR.
abnormally high.
Tx PMR
prednisone -> QUICK response
If no improvement in 2-3 weeks, unlikely PMR
NSAIDS don’t work
Who should pts w/ PMR always be referred to?
ophthalmology for blindness
What is reactive arthritis?
Auto-immune condition that can occur post infection (typically Genitourinary or Gastro-intestinal infections)
Reaction” to an infection which took place outside of the joints
what are the common pathogens responsible for reactive arthritis?
Chlamydia Campylobacter Salmonella Shigella Yersinia
what haplotype is Reactive Arthritis strongly linked to?
HLA-B27
classic triad seen in reactive arthritis
non-infectious urethritis, arthritis
conjunctivitis
CAN’T SEE, CAN’T PEE, CAN’T CLIMB A TREE
Si/Sx of reactive arthritis
Joint inflammation characterized by redness, swelling, pain and warmth in the joints.
Lower limbs and Sacro-iliac joints most effected
Inflammation of the urinary tract and the conjunctiva.
Other symptoms: fever, weight loss, lower back pain, heel pain.
how to tx reactive arthritis
Tx offending agent (antis)
prednisone for joints
DMARDS: When NSAIDs and Steroids are ineffective Sulfasalazine (good when triggered by GI)
what is JIA?
Inflammation of the CT seen in children
6 wks of pain and swelling with exclusions of other causes
what are the 5 types of JIA
polyarticular arthritis oligoarticular arthritis systemic onset enthesis (related arthritis) psoriatic arthritis
what type is JIA manifests w/ CONSTANT pain and resembles the adult form of RA?
Polyarticular arthritis
arthritis in 5 or more joints with major symptoms of pain in the knees, ankles, wrists, fingers, elbows and shoulders.
children of ANY age
JIA that manifests w/ Arthritis in 1 or more joints,
sacroilitis, DIP joint synovitis, dactylitis and nail pitting + psoriatic rash or family hx of psoriatic rash
psoriatic arthritis
child presents w/
Repeated fevers to 103F w/ fluctuating salmon colored rash. Inflammation of the internal organs, enlarged lymph nodes and spleen?
Systemic Onset arthritis
with Systemic Onset arthritis when is malignancy suspected?
with anemia and splenomegaly
Complications involve pericarditis and pericardial effusions
young boy (8 yrs old) presents w/ Pain and inflammation where the ligaments and tendons attach to bones along w/ back pain. Dx?
Enthesis (Related Arthritis)
what type of JIA has a high risk of iritis?
Oligoarticular Arthritis
young girl presents w/ asymmetrical morning stiffness in LARGE joints knees, ankles, elbows, wrists. Does not complain of much pain, mostly stiffness. Dx?
Oligoarticular Arthritis
Pt presents w/ proximal muscle weakness, upper and lower limbs, bilaterally. she complains of difficulty raising arms, lifting object over head, combing hair. Trouble climbing stairs, getting up from sitting. Dx?
Polymyositis
Polymyositis vs PMR
polymyositis - Proximal muscle weakness, upper and lower limbs, bilaterally
PMR - pain w/o WEAKNESS
what lab values would you expect to be elevated in polymyositis
MUSCLE ENZYMES
CPK
LDH
CHECK LIVER ENZYMES
define heliotrope rash
purple discoloration on upper eyelids, flat red rash on cheeks and upper trunk
Dermatomyositis
2 identifying fts of Dermatomyositis
heliotrope rash
gorttons papules
young girl complains of muscle weakness. A muscle bx is done and reveals perivascular and perimysial inflammation. dx?
dermatomyositis
Tx for dermatomyositis and polymyositis
prednisone (corticosteroids)
extra skeletal manifestations Azathioprine Cyclophosmaide Chlorambucil Cyclosporine
INF inhibitors –infliximab
Anti-CD20 (Rituximab)
60 y/o man complains of frequent FALLING along w/ weakness of DISTAL muscles and facial muscles. Dx?
inclusion body myositis
how to differentiate inclusion body myositis from polymyo and dermatomyo
inclusion body Can have asymmetrical weakness making it different than (PM, DM)
DM - rash and seen in children
what dz is associated w/ Raynaud’s phenomenon, RA, SLE, Sjogren’s, CV dz, Cancer
drugs?
polymyositis