3 - Arthritis

Question 1

MC inflammatory arthritis?

Answer 1

Rheumatoid arthritis

Question 2

MC pt population for RA?

Answer 2

Females 30-40’s

Males 50-70’s

Question 3

Define RA

Answer 3

Chronic systemic inflammatory disease of UKN cause,

• primarily targets the synovium
• Leading to loss of articular cartilage and erosion of juxta-articular bone

Question 4

Causes of RA?

Answer 4

Direct synovial infection :

• mycoplasma
• parvovirus
• retroviruses

Molecular mimickry of QKRAA

Enteric bacterial infections

• mycobacterial spp
• EBV

Question 5

Strongest association to RA?

Answer 5

HLA-DRB1

“Shared epitope”

Question 6

Presentation of RA?

Answer 6

Insidious, chronic, symmetric arthritis of:

• small joints
• hands and writsts

Start in:

• PIP
• MCP
• MTP

Question 7

Which joints are usually affected w RA

Answer 7

MCP, PIP, and MTP&raquo_space; Wrist, knee, elbow, ankles, hip, shoulders

Question 8

Joints spared by RA?

Answer 8

DIPs

T/L spine

Question 9

Late joint deformities for RA?

Answer 9

Ulnar deviation of MCP
Boutonnier deformity
Swan-neck deformity

Question 10

With RA pts you must be careful?

Answer 10

With intubation

Risk of spinal injury with C1-C2

Question 11

What should be checked with RA joints?

Answer 11

Joint effusions - synovial fluid analysis

Question 12

Extra articular manifestations of RA?

Answer 12

Rheumatoid nodules
Episcleritis
Pleural effusions

Question 13

Differenting from Sjogren’s sydrome?

Answer 13

RA is anti-Ro/Anti-La neg

Question 14

Specific RA tests?

Answer 14

RF

Anti-CCP antibodies

Question 15

T, B, complement cells?

Answer 15

RA has an activation of T cells, B cells and complement within the synovium

Question 16

Labs for RA?

Answer 16

RF
ESR/CRP
CBC
Anti-CCP
ANA
Chem/LFT
Anemia
THrombocytosis

Question 17

Synovial fluid with RA?

Answer 17

WBC 5k-50k

- 75% neutrophils

Question 18

Radiology for RA?

Answer 18

Juxta-articular erosions and joint-space narrowing

Question 19

PE for RA

Answer 19

Synovitis
Nodules
Splenomegaly

Question 20

RA non-pharm therapies?

Answer 20

Education
Exercise
Rest
Wt loss
PT/OT
Orthotic devices (splints)

Question 21

Pharmacologic therapies for RA?

Answer 21

NSAIDS
Glucocorticoids
- DMARD bridge 
Synthetic DMARD
Biologic DMARD

Question 22

Standard of care for RA?

Answer 22

Methotrexate + folic acid

Question 23

Synthetic DMARDs for RA?

Answer 23

Methotrexate + folic acid
Lefluonomide
Sulfasalazine (combo tx)
Hydroxychloroquine
Minocycline (<2yrs only)

Question 24

Least effective synthetic DMARD?

Answer 24

Hydroxychloroquine

• least effective
• renal toxicity

Question 25

Biologic DMARDs problems?

Answer 25

Effective but more expensive Increased risk for: - TB - Hep B/C - lymphoma

Question 26

Biologic DMARDS?

Answer 26

TNF-alpha inhibitiors - infliximab (remicade) - entanercept (enbrel) - adalimumab (humira) - golimumab (simponi) - certolizumab (cimzia) Selective constimulation modifier - abatacept (orencia) Interlukin-1 receptor aganost - anakinra Monoclonial antibody - rituximab (rituxin) - tocilizumab (actemra)

Question 27

MC form of childhood arthritis?

Answer 27

Juvenile idiopathat arthritis JIA

Question 28

Subgroups of JIA?

Answer 28

1. Systemic 2. Polyarticular (sero+/-) 3. Oligoarticualr 4. Psoriatic (not discussed) 5. Enthesitis-related (not discussed)

Question 29

IOT be JIA pt must have?

Answer 29

>/= 6 weeks of persistent joint swelling | Excludes other types of childhood arthritis

Question 30

S/s of JIA?

Answer 30

>/= 6 weeks of joint swelling Systemic symptoms - fevers - fatigue - pain - appear acutely ill

Question 31

Diagnostic criteria for JIA?

Answer 31

1. Age <16 2. Persistent joint swelling x 6 weeks 3. Exclusion of other causes

Question 32

What are the diagnostic lab criteria for JIA?

Answer 32

None are diagnostic but: RF + <20% ANA + 85% Often see increase in: - WBC - ESR - Ferritin - CRP - platelets - abnormal LFTs - Anemia

Question 33

Treatment for JIA?

Answer 33

Think RA, its similar REFERRAL NSAIDS Glucocorticoids (oral and IA) DMARDS (methotrexate)

Question 34

Who is prone to seropositive polyarticular arthritis?

Answer 34

Teenaged girls

Question 35

Seropositive polyarthritis has ___ joints involved?

Answer 35

>/= 5 at onset

Question 36

Seropositive polyarthritis has an ___ ___

Answer 36

Aggressive course

Question 37

Describe the course of seropositive polyarticular

Answer 37

Aggressive - Vasculitis - Nodules - Felty syndrome - Lung disease - Erosive joint disease

Question 38

What disease does seropositive polyarticular mimic?

Answer 38

Resembles the adult form of: | - classic rheumatoid factor positive RA

Question 39

Diagnostic criteria for seropositive polyarthicular arthritis?

Answer 39

Seropositive (+RF)

Question 40

Tx for seropositive polyarticular arthritis

Answer 40

Referral NSAIDS Glucocorticoids (oral, IA) DMARDs (methotrexate)

Question 41

Seronegative polyarticular affects predominatly?

Answer 41

Girls = boys 8-12 y/o

Question 42

Seronegative polyarticular s/s?

Answer 42

``` Poor wt gain/growth May/may not be: - symmetric - large joints - knees - ankles - wrists ```

Question 43

When are radiographic changes seen with Seronegative polyarticular?

Answer 43

May be several years before erosive changes are seen before erosive changes are seen on radiographs

Question 44

Diagnostic for Seronegative polyarticular?

Answer 44

Seronegative (-RF)

Question 45

Seronegative polyarticular tx?

Answer 45

REFERRAL NSAIDS Glucocorticoids (oral or IA) DMARDS (methotrexate)

Question 46

What is the MC subgroup of JIA?

Answer 46

Oligoarticular

Question 47

Patient population for Oligoarticular?

Answer 47

Girls 1-7 y/o

Question 48

Diagnostic criteria for Oligoarticular?

Answer 48

<4 joint groups

Question 49

If Oligoarticular progresses to more than 4 joints what happens?

Answer 49

< 6 mo - polyarticular arthritis >6 mo - extended oligoarticular

Question 50

Oligoarticular pts complain of?

Answer 50

Morning stiffness | MC knees

Question 51

Diagnostic blood work for Oligoarticular?

Answer 51

ANA +

Question 52

ANA pos Oligoarticular pts are at a risk for?

Answer 52

Asymptomatic iritis Get them to optho

Question 53

Oligoarticular tx?

Answer 53

Same as JIA REFERRAl NSAIDS Glucocorticoids (oral, IA) DMARDS (methotrexate)