Seropositive arthropathies Flashcards
What are the 4 types of seropositive arthropathies?
- RA
- SLE
- Scleroderma
- Dematomyositis
Hx of RA
Symmetrical
polyarthritis (small
joint involvement)
AM stiffness (>1 h)
Hx of SLE
Multisystemic disease: rash, photosensitivity, Raynaud’s, alopecia, cardiac and pulmonary serositis, CNS symptoms, glomerulonephritis
Hx of scleroderma
Skin tightness, stiffness of fingers, Raynaud’s, heartburn, dysphagia, pulmonary hypertension, renal dysfunction, dyspnea on exertion
Hx of dermatomyositis
Heliotrope rash (periorbital), Gottron’s papules (violaceous papules over knuckles and IP joints) ± poikiloderma Shawl sign macular erythema over chest and shoulder Proximal muscle weakness ± pain Dyspnea on exertion
What is dermatomyositis?
Dermatomyositis (DM) is a connective-tissue disease related to polymyositis (PM) that is characterized by inflammation of the muscles and the skin.
It may also affect the joints, the esophagus, the lungs, and the heart.
Rare
RA O/E
Effused joints (c.f. Lupus) Tenosynovitis Nodules Joint deformities Bone-on-bone crepitus
SLE O/E
Confirm historical findings
(rash, serositis, renal, CVS, etc.)
± effused (typically small)
joints (can be minimal, look for soft tissue swelling c.f. RA)
Scleroderma O/E
Skin tightness on dorsum of hand, facial skin tightening, telangiectasia, calcinosis, non-effused joint, inspiratory crackles
Dermatomyositis O/E
Rash, proximal muscle
weakness, inspiratory
crackles
Which seropositive arthropathies have reduced WBC?
RA & Lupus
Scleroderma & dermatomyositis both have normal WBC
Specific serology of RA
Rheumatoid factor (80%) Anti-CCP (80%)
Specific serology of lupus
ANA +ve in 98% Anti-dsDNA +ve in 50-70% Anti-SM +ve in 30% reduced C3, C4, total hemolytic complement False positive VDRL (in lupus subtypes) high PTT (in lupus subtypes; e.g. anti-phospholipid Ab)
Synovial fluid of seropositive arthropathies
- RA: inflammation. leukocytosis (>10,000)
- Lupus: mild inflammation with +ve ANA
- Scleroderma & dermatomyositis: not specific
Radiographic features of RA
- Periarticular osteopenia
- Joint space narrowing
- Erosions (c.f. lupus)
- Absence of bone repair
- Symmetric/concentric
Radiographic features of lupus
Non-erosive
± osteopenia
± soft tissue swelling
Define RA
- chronic, symmetric, erosive synovitis of peripheral joints (i.e. wrists, MCPs, MTPs)
- characterized by a number of extra-articular features
What is RA an independent risk factor for?
Atherosclerosis & CV disease
RA is associated with increased overall mortality/morbidity from all causes:
CV disease, neoplasm (especially lymphoma), infection.
Common Px of RA
- Morning stiffness >1 h, improves with use
- Symmetric joint involvement
- Initially involves small joints of hands and feet
- Constitutional symptoms
What does the 1987 American Rheumatism association RA criteria consist of?
RA is at least 4 of: • Morning stiffness >1 h for >6 wk • Arthritis ≥3 joints for >6 wk • Arthritis of hand joints for >6 wk • Symmetric arthritis for >6 wk • Rheumatoid nodules • Serum RF positive • Radiographic changes (erosions or periarticular osteopenia)
Criteria are 91-94% sensitive and 89% specific for RA.
What is the hallmark of RA?
hypertrophy of the synovial membrane
activated rheumatoid synovium (pannus) grows into and over the articular surface;
inflammatory mediators lead to release of metalloproteinases and collagenases resulting in
destruction of articular cartilage and subchondral bone
Who gets RA?
- prevalence 1% of adult population
- F:M = 3:1
- age of onset 20-40 yr
- genetic predisposition: HLA-DR4/DR1 association (93% of patients have either HLA type)
Joint deformities of RA
- swan neck deformity, -boutonnière deformity
- ulnar deviation of MCP, radial deviation of wrist joint
- hammer toe, mallet toe, claw toe
- flexion contractures
What is a common syndrome in RA?
Sjögren’s syndrome:
keratoconjunctivitis sicca and
xerostomia (dry eyes and mouth)
Rx of RA
- DMARDs:
- standard of care and should be started as soon as possible
- methotrexate
- delayed onset of action (8-12wk) - Biologics:
- indicated if inadequate response to DMARDs
- abatacept, rituximab, tocilizumab
- reassess every 3-6 mo and monitor disease severity - NSAIDs
- Corticosteroids
- local: intraarticular injections
- systemic: low dose (5-10 mg/d) useful for short term to improve symptoms if NSAIDs
ineffective, to bridge gap until DMARD takes effect
Surgery available for synovectomy, joint replacement, joint fusion, reconstruction/tendon
repair
Poor prognostic features of RA
young age of onset, high RF titer, elevated ESR, activity of >20 joints, and presence of EAF.
Side effects of steroids
- Weight gain
- Osteoporosis
- Avascular necrosis (AVN)
- Cataracts, glaucoma
- Peptic ulcer disease (PUD)
- Susceptibility to infection
- Easy bruising
- Acne
- Hypertension
- Hyperlipidemia
- Hypokalemia, hyperglycemia
- Mood swings
