Week 11: Inflammatory Arthritides Flashcards
For rheumatoid Arthritis
- Clinical Presentation
Rheumatoid Arthritis: Crystal
- associated arthropathies
- affects 2% of Australians 3:1 (female:male)
- Genetic susceptibility (higher concordance in mono then dizygotic twins)
- Environmental triggers: (smoking, periodontal disease, viral infections)
Clinical presentation:
- Insidious onset (joint stiffness, pain on movement, tenderness on palpating). Worsen week-month
- May have swelling in couple of joints over days to weeks (palindromic)
- eventually affects multiple joints (MCP/PIPs)
- Joint swelling (doughy/spongy). Synovitis, tenosynovitis)
- Swan-neck deformity, Boutonnière deformity
- Rheumatoid nodules
- Often results in premature mortality
For Rheumatoid Arthritis:
- Basic Pathophysiology
- chronic progressive immune-mediated inflammatory disease
- Immunological activation and inflammatory pathways
- Immune system targets the synovial membrane
Characterised by:
- Symmetrical joint involvement
- Persistent synovitis
- Synovium proliferation
- Autoimmune activation and chronic inflammation result in joint damage, pain and disability
Pannus:
- Abnormal layer of vascularised granulation tissue rich in fibroblasts, lymphocytes, macrophages
- Derived from synovial tissue
- Overgroes the joint in RA and covers articular cartilage
- Associated wit the breakdown of the articular surface
Stages of RA:
- Synovitis
- Pannus
- Fibrous ankylosis
- Bony Ankylosis
For Rheumatoid Arthritis:
- Structural Features
- symmetrical narrowing of joint space
- soft tissue swelling
- Generalised osteopaenia
- Peri-articular bony erosions
- May see joint subluxation
For Rheumatoid Arthritis
- Diagnostic criteria
A. Joint involvement: swollen, tender, small joints (wrist, thumb IP, MCP, PIP, MTP 2-5), large joints (shoulder, elbow, hip, knee)
B. Serology
C. Acute-phase reactants
D.Symptom duration (self-report)
Score >6 = definite RA
For Juvenile Idiopathic arthritis:
- Clinical Presentation
- Heterogeneous group of systemic inflammatory arthritides affecting children <16yrs
- 1 per 1,000 children (girls>boys)
- Major cause of children disability (permanent joint damage, 50% remission/permanent remission)
- Swollen, stiff, warm, red, painful joints
Disease Subsets:
- 10% systemic (rash, high fever)
- 25% Polyarticular (5 or more joints)
- 40% Pauci/Oligoarticular (4 or fewer joints involved)
- Psoriatic arthritis
- Enthesitis- related arthritis (ERA)
- undifferentiated arthritis
For juvenile idiopathic arthritis
- Basic pathophysiology
- Structural Criteria
Systemic (3-5yrs old) Still’s Disease:
- auto-immmune; cytokines
- Arthritis in >1 joint for at least 6/52 with high fever, pink rash upper trunk, swollen lymph nodes
- Visceral involvement (inflammation of the lungs)
- Only 50% recover completely
Polyarticular (late childhood- young teenagers)
- > 5 joints (small and large)
- RF knees/wrists
- RF+ more aggressive, resembles adult onset RA
Pauci/Oligoarticular (2-4yrs old)
- Mostly presenting at <5 years, <4 joints (mostly knee, ankle, elbow)
- Eye manifestations (uveitis)
- Good prognosis
Enthesitis-related arthritis:
- arthritis and inflammation of entheses (tendon-bone insertions (spine, heels, hips, knees, ankles)
Psoriatic arthritis:
- Psoriasis with Arthritis
- Eye manifestations (uveitis)
Undifferentiated Arthritis
- Sx of two or more types, or other
For Juvenile idiopathic arthritis
- Diagnostic Criteria:
- Age at onset <16 yrs
- Arthritis in one or more joints, i.e. articular swelling/effusion for at least 6 weeks
- Presence of two or more (limitation of ROM, joint tenderness, pain on joint movement, heat over join, exclusion of other causes of arthritis)
For Rheumatoid Arthritis
- Medical Management:
- Early referral to a rheumatologist as irreversible joint damage occurs early
- Clinical remission is the treatment goal
- Symptom relief
- Normalise inflammatory markers
- Reduce Disease activity score
Medications:
- Analgaesics
- Convential disease modifying anti-thematic drugs (DMARDs)
- New DMARDS
For Rheumatoid Arthritis
- Non-pharmacological management
- increase muscle strength
- Increase endurance/aerobic capacity
No adverse effects on disease activity
Examples:
- Pilates
- Home exercise program
- Aquatic aerobic fitness
- Cardio-karate aerobic exercise
Others:
- Appropriate footwear
- Orthoses
- Splints
For Ankylosing Spondylitis
- Clinical presentation
- group of immune-mediated inflammatory diseases mainly affecting the axial skeleton (sacroiliac joint and spine) (can affect peripheral joints)
- Approximately 2% Australian population, mostly men (3:1)
Slow onset, often delay in diagnosis
For Ankylosing Spondylitis
- Structural features
Syndesomphyte:
- Bony growth originating inside a ligament
- MRI scan detect early signs of sacroiliitis
For Ankylosing Spondylitis
- Diagnostic Criteria
- low back pain >3 months
- Limitation lumbar spine ROM
- Chest expansion decreased
At least one of the above and:
- Bilateral sacroiliitis (grade 2-4)
- Unilateral sacroiliitis (grade 3-4)
Grade 2: sclerosis, some erosions
Grade 3: severe sclerosis, some ankylosis
Grade 4: complete ankylosis
Red Flags:
- Inflammatory back pain
For Ankylosing Spondyliitis
- Medical Management
- Paracetamol, NSAIDs, conventional DMARDs, biologic
- Anti-TNF therapy, but long-term consequences unknown
For Ankylosing Spondyliitis:
- Non-Pharmacological management (Physiotherapy)
- maintain posture, spinal flexibility, aerobic fitness, strength
- Needs to be regular and ongoing
- Prognosis good now, despite range of extra-articular manifestations: eye inflammation, cardiac abnormalities, pulmonary fibrosis, etc
