T&O: RA

Question 1

Outline the pathophysiology of RA

Answer 1

Chronic systemic inflammatory disease of unknown cause

Synovial cell hyperplasia and endothelial cell activation are early events in the pathologic process that progresses to uncontrolled inflammation and consequent cartilage and bone destruction

Question 2

What are the symptoms of RA.

Answer 2

Insidious onset = fever, malaise, arthralgias, weakness

Severity of RA may fluctuate over time

Stiffness

Tenderness

Pain on motion

Swelling

Ulnar deviation

Hammer toes

Boutonniere = nonreducible flexion at the PIPJ, hyperextension of the DIPJ

Swan-neck deformity = hyperextension at the PIPJ with flexion of the DIPJ

Limitation of motion

Extra-articular manifestations

Rheumatoid nodules

Question 3

How would you investigate RA?

Answer 3

Bloods = ESR, CRP, FBC, Rheumatoid factor (RF) assay, antinuclear antibody (ANA) assay, anti−cyclic citrullinated peptide (anti-CCP)

X-ray

• L = loss of joint space
• E = erosions
• S = soft tissue swelling
• S = soft bone (osteopenia

MRI – cervical spine

Aspiration = WBC count >2000/µL, generally in the range of 5000-50,000/µL

Question 4

How would you manage RA?

Answer 4

Exercise

Diet

Massage

Counselling

Stress reduction

Physical therapy

Non/biologic disease-modifying antirheumatic drugs (DMARDs) = methotrexate (1st line), hydroxychloroquine, sulfasalazine

Surgery = Synovectomy, Tenosynovectomy, Tendon realignment, Reconstructive surgery or arthroplasty, Arthrodesis

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Immunosuppressants

Steroids = prednisolone - reduce symptoms/inflam

Question 5

What are the extra-articular manifestations of RA?

Answer 5

3A’s

• Anaemia
• Amyloidosis
• Arteritis

3C’s

• Carpal tunnel syndrome
• CVD = coronary arterial disease
• Cord compression Raynauds phenomenon

3P’s

• Pericarditis
• Pleural disease
• Pulmonary disease = fibrosis, nodules

3S’s

• Sjogren’s
• Scleritis/episcleritis
• Splenic enlargement