Rheumatoid Arthritis Flashcards
1
Q
Describe the Aetiology of Rheumatoid Arthritis
A
- Gender: women are affected 3 times more often than men
- Genetic factors: Increase incidence in first degree relative and high concordance in twins.
- Environment: Smoking and other forms of bronchial stress increase risk of RA
2
Q
Describe the Pathophysiology of Rheumatoid Arthritis
A
- Synovial hypertrophy and chronic inflammation leads to joint damage
- Modification of our own antigens so no longer recognisable as self antigens. APC present these antigens to activate T-Helper cells
- Leads to Plasma cells prudction and autoantibody production
- Antibodies enter blood stream and enter joint space
- T cells recruit macrophages into the joint space (Interferon-y, Interferon-17). Macropahe produce cytokines (IL-1, IL-6, TNF-a)
- This leads to Pannus formation which overtime damages cartilage, soft tissue and bone. Protesae released by activated synovial cells which can also break down cartilages
- Exposure of RANKL can leads to osteoclastic activaton by T cells
- Increased secretion of Rheumatoid Factor and ANTI-CCP into joint space which form immune complexes to activate the complement system leading to further damage
- Chronic inflammation also causes angiogenisis which increase the number of immune cells that arrive
3
Q
What are pathological changes seen in Rheumatoid Arthritis?
A
- Nodules
- Central fibrinous necrosis with surrounding macrophages and fibroblasts
- Synovium
- Inflammatory infiltrate of T lymphocytes, plasma cells, macrophages
- Inflammation extends to subchondral bone
- Proliferative synovitis with synovial cell hyperplasia and hypertrophy
4
Q
What are some symptoms of Rheumatoid Arthritis?
A
- Pain and stiffness of hands (MCPs, PIPs) and feet (MTPs). DIPs usually spared.
- Worse in the morning
- Wrists, Elbows, Shoulders, Knees and Ankles are also affected
- Fatigue and disturbed sleep
- Joints are warm and tender with some swelling
5
Q
What are Articular Complications of Rheumatoid Arthritis?
A
- Septic Arthritis
- Amyloidosis
- Hands and Wrist deformities
- Subcutaneous nodule which are firm and intradermal occurring at pressure points
- Tenosynovitis of flexor tendons of hands
- Muscle wasting around joint
6
Q
What are some hand and wrist deformities seen as a result of Rheumatic Disease?
A
- Ulnar deviation and palmar subluxation
- Fixed flexion of PIP joints – boutonniere deformity
- Fixed hyperextension of PIP – swan neck deformity
- Swelling and dorsal subluxation of ulnar styloid which causes wrist pain and may cause rupture of finger extensor tendons leading in turn to sudden onset of finger drop of little and ring fingers predominantly
7
Q
What are the extra articular presentations of Rheumatoid Arthritis?
A
- Anaemia
- Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
- Ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
- Increased risk of infections
- Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
- Depression
- Osteoporosis
- Vasculitis
- Pericarditis
- Peripheral sensory neuropathies: mononeuritis multiplex or symmetrical, peripheral – due to vasculitis of the vasa nervorum.
- Felty’s syndrome (RA + splenomegaly + low white cell count)
- Atlantoaxial subxalation
- Amyloidosis
8
Q
What are tests for Rheumatoid Arthritis?
A
- Rheumatoid Factor
- Rose-Waaler Test
- Anti-CCP
- USed if Rheumatoid Factor negative
- X-Ray of hands and feet if suspected
- Used as benchmark
9
Q
What should be done one Rheumatoid is confirmed?
A
- Measure anti-CCP antibodies unless already measure
- X-ray of the hands to establish whter erosion present unless already done
- Measure functioning ability using HAQ
10
Q
What is the non-pharmocological management for Rheumatoid Arthritis?
A
- Improve general fitness and regular exercise. Learn exercise for enhancing joint flexibility, muscle strength and managing other functional impairments
- Short term pain relief
- Occupational therapy
- Podiatry if they have any problems with feet
11
Q
What is the pharmacological management of Rheumatoid Arthritis?
A
-
1st Line: DMARDs such as Methothrexate, Leflunomide
- If not effective, add a second DMARD
- Consider used Steroid Bridging therapy
- Ig not managed by DMARDs still then can add monclonal antibody treatment such as Rituximab, Sarilumab
12
Q
When is surgical management sought for Rheumatoid Arthritis?
A
- Offer adults early specialist surgical opinion if any of following do not respond to optimal non-surgical management
- Persistent pain due to joint damage or other identifiable soft tissue cause
- Worsening joint function
- Progressive deformity
- Persistent localised synovitis
- Offer to refer adults with any of following complications for specialist surgical opinion before damage or deformity becomes irreversible
- Imminent or actual tendon rupture
- Nerve compression
- Stress fracture
13
Q
What are the main expected benefits of surgical intervention?
A
- Pain relief
- Improvement or prevent of further deterioration of joint function and
- Prevention of deformity
14
Q
What is done if Cervical Myelopathy is suspected?
A
- Request an urgent MRI scan and
- Fer for specialist surgical opinion
15
Q
What is Systemic Lupus Eythematosus?
A
An autoimmune disorder.
- It typically presents in early adulthood and is more common in women and people of Afro-Caribbean origin
- Characterized by remissions and flares.
- Can be familial
