Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MSK-Derm by Minnie AH Version > SM 234a - Rheumatoid Arthritis > Flashcards

SM 234a - Rheumatoid Arthritis Flashcards

You may prefer our related Brainscape-certified flashcards:
Dermatology Board Prep flashcards
1
Q

What class of medications are the mainstay of long-term RA management?

A

DMARDs (Disease-modifying anti-rheumatic drugs)

  • Methotrexate = most effective single non-biologic DMARD
  • Biologic DMARDs (-imab and -umab drugs) are very effective at modifying disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What does a positive ACPA predict about a patients RA prognosis?

A

Positive ACPA = worse prognosis

  • Erosive disease, extra-articular manifestations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the most common and severe side effects of long-term corticosteroid use?

A

Osteoporosis

HTN

Hyperglycemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

Involves PIP and DIP

A

Osteoarthritis

(MCP is spared in osteoarthritis, usually involved in RA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Which antibody is most specific for RA?

A

Anti-citrullinated peptide antibody (ACPA)

  • aka anti-cyclic citrullinated peptice (anti-CCP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe the make-up of a normal synovium

A
  • Intimal lining
    • Macrophage-like synoviocytes (MLS) and fibroblast-like synoviocytes (FLS)
    • Allows delicate, leaky, free movement of cells and proteins into synovial fluid
  • Sublining
    • Fibroblasts, adipocytes, blood vessels, immune cells

Produce lubricants for and provide nutrients to cartilage

(cartilage lacks its own blood supply)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

Asymmetric

A

Osteoarthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the usual age of onset for rheumatoid arthritis?

A

40-60 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How are symptoms of RA treated acutely?

A
  • NSAIDs
    • Symptomatic relief only, will not prevent disease progression
  • Corticosteroids
    • More effective than NSAIDs, but more side effects
    • Intra-articular or systemic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What autoantibodies are most commonly seen in patients with RA?

A
  • Rheumatoid factor (RF)
    • Specific for RA
  • Anti-citrullinated peptide antibodies (ACPA)
    • Specific for RA
  • Anti-nuclear antibody
    • Not sensitive or specific for RA
    • Positive in 20-30% of patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Demineralization of this pattern is associated with what kind of arthritis?

A

Rheumatoid arthritis

  • Shows ulnar styloid erosion + demineralized cortex
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is rheumatoid factor?

A

Autoantibody with specificty for Fc fragment of IgG

  • Sensitivity = 66%, specificity = 82% for RA
    • Important to check ACPA too; 35% of patients with negative RF will have positive ACPA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How does the synovium change in rheumatoid arthritis?

A
  • Intimal lining expands
    • Activated synoviocytes produce pro-inflammatory cytokines
  • Sublining
    • Adaptive immune cells infiltrate the sublining
    • Hypervascularity
  • Pannus formation
    • ​Invasive, destructive front of synovial tissue attached to the articular surface
    • Contains activated osteoclasts that degrade bone at the edge of the pannus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the mechanism of methotrexate?

A

Inhibits dihydrofolate reductase

-> inhibition of DNA synthesis

  • Inhibits vascular proliferation
  • Inhibits neutrophil activation and adherance
  • Inhibits IL-1, IL-8 production by mononuclear cells
  • Inhibits TNF production by T cells

First-line DMARD used to manage RA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What causes bone degradation in rheumatoid arthritis?

A

Osteoclasts living within the pannus

  • Pannus = invasive, destructive front of synovial tissue attached to the articular surface
    • Interfaces with bone
    • Contains osteoclasts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

All MTPs may be involved

A

Rheumatoid arthritis

(Osteoarthritis usually only affects 1st MTP)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are ACPAs?

A

Anti-Citrullinated Peptide Antibodies (aka anti-cyclic citrullinated peptide (Anti-CCP)

  • Sensitivity 75%, Specificity 95% for RA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the risk factors of RA?

A
  • Genetic
    • HLA-DRB1*01, HLA-DRB1*04
  • Female sex
  • Environmental factors -> changes in DNA methylation
    • Smoking
    • Dust inhalation
    • Microbiota
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the classic radiographic finding in RA?

A

Juxta-articular erosions

  • May not be present at presentation
  • Do not wait until these appear to initiate treatment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the cardinal features of rheumatoid arthritis?

A

Synovitis + Joint damage

  • Driven by IL-1, IL-6, TNF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the characteristics of preclinical RA?

What is happening pathogenically?

A

Asymptomatic autoimmunity/Early symptomatic autoimmunity

  • Peptidylarginine deaminases (PADs) convert peptidylarginine to peptidylcitrulline, in a process called citrullination
    • PADs can be induced by environmental factors
  • Peptidylcitrulline induces an immune response
    • APCs migrate to lymphoid tissues and activate T cells
    • T cells stimulate B celsl to produce autoantibodies
      • Rheumatoid factor (RF)
      • Anti-citrullinatied peptide antibody (ACPA)
22
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

MCP and PIP joints involved

A

Rheumatoid arthritis

(DIP usually spared)

23
Q

Describe the presentation of inflammatory arthritis

A

Insidious onset of symmetric polyarthritis (>3 joints), esp. in the small joints of hands and feet

  • Joint swelling
  • Decreased range of motion
  • Pain and swelling is worse in the morning
    • Stiffness lasts >1 hour
  • Stiffness after rest
24
Q

All of the following lab abnormalities might be seen in RA except:

A) Normochromic normocytic anemia

B) Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies

C) Microcytic anemia

D) Positive double stranded DNA (anti-dsDNA)

E) Positive antinuclear antibody (ANA)

F) Positive rheumatoid factor (RF)

G) Neutropenia

H) Thrombocytopenia

A

D) Positive double stranded DNA (anti-dsDNA)

Anti-dsDNA is specific for lupus

25
Q

HLA-DRB1*01 and HLA-DRB1*04 are risk factors for which disease?

A

Rheumatoid arthritis

26
Q

Which non-biologic DMARD should never be given to women who might become pregnant now or want to become pregnant in the future?

Why?

A

Leflunomide

Teratogenic with a very long half-life (due to enterohepatic ciruculation)

27
Q

What is the most common cause of premature death in patients with RA?

A

Cardiovascular disease

  • Arthrosclerosis develops earlier
  • May be driven by the systemic inflammation in RA
28
Q

What are the goals of treatment for a patient with RA?

A

Reduce joint pain and swelling

Prevent joint damage

Treat to target (until remission is attained)

29
Q

Which proinflammatory factors stimulate osteoclasts in RA?

A

IL-1, IL-6, TNF, RANKL

APCAs may also activate osteoclasts

30
Q

What are the characteristics of early RA?

A

Undifferentiated arthritis

  • The immune system is ramping up, causing inflammation in the joints
31
Q

What are the common causes of mortality in patients with RA?

A

CVD (most common)

Infection

Cancer

Amyloidosis -> renal disease

32
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

Bony enlargement of joints

A

Osteoarthritis

(RA usually invovles swelling, not bony enlargement)

33
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

Insidious onset

A

Both

34
Q

When would you add a biologic DMARD to the treatment regimen of a patient with RA?

A

If disease activity is still moderate-high after starting methotrexate

35
Q

Describe the differences in hand involvement typically seen in RA vs. OA

A
  • RA – MCPs and PIPs involved (DIPs spared)
  • OA – PIPs and DIPs involved (MCPs spared)
36
Q

Pannus formation is characteristic of which bone disease?

A

Rheumatoid arthritis

  • Attached to the articular surface
  • Interfaces with bone
  • Contains osteoclasts that degrade bone
37
Q

Which bacteria are associated with the development of RA?

A
  • Periodontal: P. gingivalis
  • Gut: Prevotella spp.
38
Q

What is the role of citrullination in the pathogenesis of RA?

A

Citrullinated peptides induce the autoimmune response

  • Environmental stressors at mucosal sites induce peptidylarginine deaminases (PADs)
  • PADs convert peptidylarginine to peptidylcitrulline, in a process called citrullination
  • Citrullinated peptides bind to HLA protein heterodimers on APCs
  • APCs present citrullinated peptides to T cells
  • T cells stimulate B cells to produce autoantibodies
    • ​Rheumatoid factor
    • Anti-citrullinated peptide antibody
    • These antibodies can be detected up to 10 years before joint pain begins
39
Q

In RA, what critical step leads to immune activation and production of RF and ACPAs?

A

Citrullination

40
Q

Describe the differences in spine involvement typically seen in RA vs. OA

A
  • RA – Cervical spine
  • OA – Cervical or lumbar spine
41
Q

What is happening pathogenically in early RA?

A

Recall: preclinical = production of RF and ACPA, due in part to citrullination

  • Influx of inflammatory cells into the synovium
    • CD4+ T cells, macrophages, APCs
    • B cells and plasma cells produce autoantibodies
  • Activated synoviocytes produce pro-inflammatory cytokines and proteases
    • Macrophage-like synoviocytes: IL-1, IL-6, TNF
    • Fibroblast-like synoviocytes: MMPs, RANKL
  • Cytokines enhance and perpetuate joint inflammation
42
Q

What is the first-line medication for the long-term treatment of RA?

A

Methotrexate

Add others (biologic) if inadequate or non-response

43
Q

Describe the differences in foot involvement typically seen in RA vs. OA

A
  • RA – All metatarsophalangeal joints as well as midfoot
  • OA – Usually only the first MTP
44
Q

What is atlantoaxial subluxation?

Why is this dangerous?

A

Partial dislocation of the atlantoaxial joint (between C1 and C2)

  • Potential complication of RA
  • Risk of spinal cord compression if the anterior distance between C1 and C2 is >8 mm (normal = 2.5-3 mm)
  • Risk of intubation during anesthesia
45
Q

Citrullination is part of the pathogenesis of which bone disease?

A

Rheumatoid arthritis

46
Q

Which factors are produced by macrophage-like synoviocytes (MLS) in early RA?

Which factors are produced by fibroblast-like synoviocytes (FLS)?

A
  • MLS
    • IL-1, IL-6, TNF
  • FLS
    • MMPs
      • Destroy cartilage
    • RANKL
      • Stimulates osteoclast differentiation
47
Q

Characteristic of osteoarthritis or rheumatoid arthritis?

Morning stiffness lasting >1 hour

A

Rheumatoid arthritis

48
Q

Describe the synovial fluid analysis consistent with RA

  • WBC count?
  • Crystals?
  • Cultures?
A
  • WBC count: 5,000 - 50,000
    • >50,000 consider osteomyelitis or joint infection
  • Crystals
    • None
  • Cultures
    • Negative
49
Q

What disease does this patient most likely have?

Describe the relevant radiographic findings

A

Rheumatoid arthritis

  • Diffuse joint space narrowing
  • MCP subluxation (partial dislocation), ulnar deviation
  • Demineralization
  • Marginal erosions at MCPs
50
Q

What are the major mediators of joint damage in RA?

A
  • Cartilage destroction
    • MMPs
  • Bone erosion
    • Osteoclasts, stimulated by…
      • IL-1, IL-6
      • RANKL
      • Maybe ACPAs too
51
Q

What are the radiographic changes typically seen in patients with RA?

A
  • Soft tissue swelling
  • Periarticular osteopenia
  • Uniform/symmetric joint space loss/deformity
    • Osteoarthritis is usually not symmetric
  • Marginal erosions
    • Due to the osteoclast-containing pannus eating away at the bone

MSK-Derm by Minnie AH Version (47 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions