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Rheumatology > 2: Autoimmune Inflammatory Arthritis > Flashcards

2: Autoimmune Inflammatory Arthritis Flashcards

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1
Q

what is rheumatoid arthritis

A

Inflammatory autoimmune disease characterised by joint pain, swelling and synovial destruction

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2
Q

in which gender is rheumatoid arthritis more common

A

Females (4:1)

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3
Q

what is the peak incidence for rheumatoid arthritis

A

50-75y

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4
Q

what causes rheumatoid arthritis

A

Combination of genetic and environmental factors. Genetic factors include HLADR1 and HLADR4. Environmental includes smoking + infection.

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5
Q

explain how rheumatoid arthritis presents

A
  • Symmetrical polyarthritis
  • Tends to affect smaller joints
  • Morning stiffness >30m
  • Swollen and painful joints (often without erythema)
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6
Q

which joints does RA typically affect

A

MCP and PIP

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7
Q

what is a never event in RA

A

That it affects DIPs

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8
Q

what are 5 signs of the rheumatoid hand

A
  • Guttering
  • Swan neck
  • Boutoneire’s
  • Z-shaped
  • Positive squeeze test
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9
Q

what is guttering

A

Wasting of the interoessi muscles

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10
Q

what is swan neck deformity

A
  • Hyperextension at PIPS

- Flexion at DIPS

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11
Q

what is boutonniere deformity

A
  • Flexion at DIPs

- Hyperextension at PIPs

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12
Q

what is z-shaped deformity

A

Flexion at MCP, Hyperextension at DIPs

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13
Q

what is flexion at the PIPs and hyper-extension at the DIPs called

A

Boutonierre’s

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14
Q

what is hyperextension at the PIPS and flexion and the DIPS called

A

Swan neck

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15
Q

what is hypertension at the DIPS with flexion at the MCP joint called

A

Z-shaped deformity

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16
Q

What is a positive squeeze test

A

when there is pain on squeezing over MCP or Meta-tarsal joints

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17
Q

What is a deformity of the spine that can be present in rheumatoid arthritis

A

Atlanto-axial subluxation

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18
Q

What is a deformity of the feet that can be present in RA

A

Hammer toe

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19
Q

What are 4 constitutional symptoms of RA

A
  • Malaise
  • Low grade fever
  • Myalgia
  • Night sweats
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20
Q

What is a deformity of the skin present in RA

A

Rheumatoid nodules

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21
Q

what are 2 lung problems that may be present in RA

A

Fibrosis

Pleural effusion

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22
Q

what are 3 eye problems that can be present in RA

A

Episcleritis
Keratoconjunctivitis
Scleritis

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23
Q

what haematological disease is present in RA

A

Normocytic normochromic anaemia

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24
Q

how will RA of the cervical spine present

A

Atlanto-axial subluxation

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25
What is felty syndrome
A severe form of seropositive RA. Presents with a triad of symptoms
26
What is the triad in felty syndrome
- Arthritis - Neutropenia - Splenomegaly
27
Explain the pathophysiology of RA
- autoimmune disorder triggered by interaction of genetic + enviroemntal - citrullination (arginine to citrulline) occurs in type II collagen - Susceptibility genes (HLA DR1 and HLA DR4) mean immune cells do not recognise the citrullinated protein and activate CD4 cells - CD4 causes prolifération of B cells to produce antibodies which enter joints - CD4 cells also recruit macrophages (using IL17 and IFNg) which then release TNFa, IL1 and IL6 which cause synovial cells to proliferate forming a pannus
28
What 4 investigations are ordered in RA
1. CRP and ESR 2. anti-CCP 3. RF 4. X-ray
29
How will CRP and ESR present
Raised
30
What antibody is very specific for RA
anti-CCP
31
What is rheumatoid factor
IgM antibody
32
What is the problem with rheumatoid factor
low specificity
33
What criteria is used to diagnose rheumatoid arthritis
American College of Rheumatology Criteria
34
What score on the american college of rheumatology criteria defines RA
>6/10
35
What are the 4 categories in the american college of rheumatology criteria
1. Joint involvement 2. Antibodies (RF, ACPA) 3. Serology (CRP, ESR) 4. Duration of symptoms (> or < 6W)
36
if individuals have suspected RA, what x-rays should be ordered
X-ray of the hands and feet
37
What is a mnemonic to remember the 3 early signs of RA on x-ray
JLS
38
What ate the late findings of RA on x-ray
Juxta-articular osteopenia Loss of joint space Soft-tissue swelling
39
What score is used to look at the activity of RA for a patient
DAS28
40
What are the 4 domains of the DAS28 score
1. No. swollen joints 2. No. tender joints 3. ESR + CRP 4. Subjective (line 1-10cm)
41
What score indicates active disease in DAS28
>5.1
42
What score indicates low disease activity in DAS28
<3.2
43
What score indicates remission in DAS28
<2.6
44
What is first-line management for RA
disease modifying anti-rheumatic drugs (DMARD)
45
What are the 4 dMARDs that could be offered
1. Methotrexate 2. Sulfalazine 3. Hydroxycholorquine 4. Lefluonomide
46
what is the most common dMARD offered
Methotrexate
47
What monitoring is required for methotrexate
FBC + LFT
48
Why is FBC and LFTs monitored for methotrexate
Due to risk of myelosupression and liver cirrhosis
49
Which is the only dMARD considered safe for pregnancy
Sulfasalazine, hydroxychloroquine
50
What is second-line treatment for RA
Biological agents
51
What are the criteria for sarliumab
DAS28 >5.1
52
What is the mechanism of action of Sarliumab
monoclonal antibody raised against IL6
53
What are 4 alternatives to sarliumab
etanercepts, infiximab, adalimumab
54
What is third-line medication for RA
rituximab
55
What is the MOA of ritxuimab
anti CD20 and therefore depletes B cells
56
What is the criteria for rituximab
- DAS28 >5.1 | - Tried methotrexate and at least on other anti-TNF
57
What are 5 factors associated with poor prognosis of RA
``` Female Onset >60 Smoker Prolonged progression Raised CRP, ESR, RF, ACPA ```
58
What are 5 complications of RA
1. Joint deformity 2. Lung fibrosis 3. Myocarditis 4. Pericarditis 5. Amyloidosis 6. Septic arthritis 7. Sjogren's syndrome
59
What is psoriatic arthritis
Seronegative spondyloarthropathy that occurs with psoriasis
60
What gene is present in 50% of cases of psoriatic arthritis
HLAB27
61
what % of individuals with cutaneous arthritis will develop joint arthritis
10-20%
62
What are the 5 patterns of psoriatic arthritis
1. Asymmetrical oligoarthritis 2. Arthritis mutilants 3. Psoriasis spondyloarthropathy 4. DIP predominant 5. Symmetrical, RF negative arthritis
63
What is the main presentation of psoriatic arthritis
Asymmetrical oligoarthritis (MCP, DIP, PIP) (70%)
64
How does psoriatic arthritis differ from RA
It is asymmetrical oligoarthritis, whereas RA is typically symmetrical
65
What is arthritis mutilans
Severe form of psoriatic arthritis that presents with telescoping of the fingers
66
What joint does psoriatic spondyloarthropathy affect
Spine (40%)
67
OE/ what may be seen in psoriatic arthritis
Erythematous, silver scaly patches over extensor surfaces (hands + knees)
68
Do joint symptoms or cutaneous symptoms come first in majority of individuals
Cutaneous - often precede joint symptoms by several years in 75%
69
What surface is the rash in psoriasis over
Extensor
70
How may fingers present in psoriatic arthritis
Dactylitis
71
How may nails present in psoriatic arthritis
- Onychodystrophy (Pitting) | - Onycholysis
72
How may eyes present in psoriatic arthritis
Chronic uveitis
73
How may joints present in psoriatic arthritis
Tenosynovitis
74
What criteria is used for psoriatic arthritis
CASPAR
75
What 6 items is the CASPAR criteria based on
1. Evidence psoriasis (FHx, cutaneous) 2. Nail dystrophy 3. Negative RF 4. Dactylitis 5. Radiologyical
76
What 3 findings may be seen on x-ray of the hands in psoriatic arthritis
1. Fluffy periostitis 2. Pencil in cup deformity 3. Acroosteolysis
77
What is pencil in cup deformity
Re-absorption of head of middle phalanx and widening of base of distal phalanx
78
What is acrostolysis
Reabsorption of distal phalanx
79
How may the spine present
Syndesmophytes | Paravertebral ossification
80
How is mild psoriatic arthritis managed
NSAIDs, PPI
81
How is moderate psoriatic arthritis managed
dMARDs
82
What investigation should be performed prior to starting someone on anti-TNF for RA and why
chest x-ray, to check for TB. As anti-biologics may cause re-activation

Rheumatology (10 decks)

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