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BRS 1b > 9.5 Rheumatoid Arthritis > Flashcards

9.5 Rheumatoid Arthritis Flashcards

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1
Q

What are the 2 types of crystal arthritis?

A

gout

pseudogout

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2
Q

What is a tendon?

A

cords of strong fibrous collagen tissue attaching muscle to bone

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3
Q

What is a ligament?

A

flexible fibrous connective tissue which connects two bones

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4
Q

What are the four components of a synovial joint?

A

Bone
Articular cartilage
Synovium
Synovial fluid

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5
Q

Why is chronic inflammation of the synovium bad?

A

leads to permanent damage; inflammatory markers can also attack articular cartilage leaving exposed bone

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6
Q

What is the synovium?

A

1-3 cell deep lining containing macrophage-like-phagocytic cells (type A synoviocyte) and fibroblast-like cells that produce hyaluronic acid (type B synoviocyte)
AND
Type 1 Collagen

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7
Q

What is the synovial fluid?

A

hyaluronic acid-rich viscous fluid

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8
Q

What is the articular cartilage?

A

Type 2 Collagen

Proteoglycan (aggrecan)

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9
Q

What is arthritis?

A

disease of the joints

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10
Q

What are the main two types of arthritis?

A

Degenerative (osteoarthritis)

Inflammatory (rheumatoid)

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11
Q

What is inflammation?

A

A physiological response to deal with injury or infection

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12
Q

What are the 5 clinical manifestations of inflammation?

A 
red (rubor)
pain (dolor)
hot (calor)
swelling (tumor)
loss of function
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13
Q

What are 4 physiological, cellular and molecular changes we see when inflammation occurs? (not 5 clinical manifestations)

A
  • increased blood flow
  • migration of white blood cells (leucocytes) into the tissues
  • activation/differentiation of leucocytes
  • cytokine production (TNF alpha, IL-1,6,17)
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14
Q

What are 3 causes of joint inflammation?

A

Crystal arthritis
Immune mediated-arthritis
Infection

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15
Q

What is crystal arthritis?

A

Inflammation of the joint triggered by crystals of synovial fluid

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16
Q

What is gout?

A

syndrome caused by deposition of monosodium urate (uric acid) crystals

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17
Q

What are the risk factors for gout?

A

high uric acid levels
genetic tendency
increased intake of purine rich foods
reduced excretion (kidney failure)

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18
Q

How does gout present?

A 
abrupt onset (couple of hours)
extremely painful 11/10
joint red, warm, swollen, tender
resolves spontaneously in 3-10 days
affects one large joint - usually big toe
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19
Q

What is pseudogout?

A

syndrome caused by calcium pyrophosphate dihydrate crystal deposition crystals (CPPD)

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20
Q

What are the risk factors for pseudogout?

A

background osteoarthritis
elderly patient
intercurrent infection

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21
Q

What will you see on an X ray showing gout

A

rat bite errosions

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22
Q

How to investigate gout?

A

joint aspiration- synovial fluid analysis

can blood test to show high uric acid levels

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23
Q

What medication is prescribed for gout?

A

acute - colchicine, NSAIDs, steroids

chronic - allopurinol

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24
Q

How are synovial fluid samples examined for pathogens and crystals?

A

rapid gram stain followed by culture and antibiotic sensitivity assays
polarising light microscopy to detect crystals

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25
What will analysis of crystals in gout show?
crystal: urate shape: needle birefringence (polarising light microscopy): negative
26
What will analysis of crystals in pseudogout show?
crystal: CPPD shape: brick birefringence: positive
27
What is rheumatoid arthritis?
chronic autoimmune disease characterised by pain stiffness and symmetrical synovitis
28
What happens to the synovium in RA?
29
What controls the immune activation in RA?
Cytokine network
30
What causes the synovitis, bone erosion, pannus and cartilage degradation in RA?
Excess of pro-inflammatory vs anti inflammatory cytokines
31
What is the main pro-inflammatory cells in RA?
TNFa
32
What’s the pattern of joint involvement in RA?
Polyarthritis - many joints involved | Affects large and small joints, primarily MCP and PIP in hands
33
What is the primary site of pathology in RA?
The synovium
34
What are som extra-articular features of RA?
Common: Fever Weight loss Subcutaneous nodules ``` Uncommon: Vasculitis Ocular inflammation Neuropathies Amyloidosis ```
35
What are subcutaneous nodules?
Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue
36
What % of RA patients have subcutaneous nodules?
30% | Associated with severed disease and extra-articular manifestations and high levels of RF
37
Where is the typical position of the rheumatoid nodule?
Ulnar body of forearm | Hands
38
What are the two types of antibodies found in the blood of RA patients?
1. Rheumatoid Factor | 2 Antibodies to citrullinated protein antigens (ACPA)
39
What is RF?
Antibodies which recognise the Fc portion of IgG antibody
40
How many RA patients are RF positive?
70% | Further 10-15% after 2 years of diagnosis
41
What does it mean if a patient is seronegative?
Absence of RF (in case of RA)
42
What is the treatment goal of RA?
Prevent joint damage
43
What requires successful treatment of RA?
Early recognition of symptoms, referral, diagnosis Joint destruction = inflammation x time Aggressive treatment
44
What types of drugs are given to RA patients?
DMARDs | Disease modifying anti rheumatic drugs = drugs that control the disease process
45
What is the 1st line treatment for RA?
Methotrexate with hydroxychlorquine
46
What is the 2nd line treatment for RA?
Biological therapies and targeted treatment
47
Why don’t we prescribe prednisolone for RA?
Avoid long term use because of side effects
48
What do we use in conjunction with medical treatment for RA?
Physiotherapist Occupational therapy Surgery Etc
49
What are biological therapies?
Proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine
50
What are the 4 biological therapies for RA?
1. Anti TNF (infliximab) 2 B cell depletion (rituximab) 3. Modulation of T cell co stimulation 4. Inhibition of interleukin 6 signalling
51
What is a spondyloarthropathy?
Joint disease of vertebrae
52
What does seronegative mean?
No positive auto antibodies
53
What is ankylosing spondylitis
Seronegative spondyloarthropathy Chronic sacroillitis - inflammation of sacroiliac joints Results in spinal fusion
54
What is the common demographic for a patient with AS?
20-30 year old male
55
What is AS associated with?
HLA B27 Psoriatic arthritis IBD
56
How does AS present?
``` Lower back pain Early morning stiffness - improves with exercise Reduced spinal movements Peripheral arthritis Plantar fasciitis, Achilles tendinitis Fatigue Hyperextended neck ```
57
How to we manage AS?
Physiotherapy Exercise regime NSAIDs If peripheral joint disease - DMARDs
58
What will we see in the blood for AS?
Normocytic anaemia Raised CRP, ESR HLA-B27
59
What is HLA-B27?
human leukocyte antigen B27 HLA is protein that is found on the surface of white blood cells, tells body it is self HLA-B27 destroys it, indicated autoimmune disease
60
What would an x ray of AS show?
``` Squaring vertebral bodies Erosion, sclerosis Narrowing sacroiliac joint Bamboo spine Bone marrow oedema ```
61
What is psoriatic arthritis?
Seronegative autoimmune disease affecting the skin (scaly red plaques on extensor surfaces elbows and knees), but patients also have joint inflammation. Psoriatic arthritis is 10% of psoriasis
62
How can psoriatic arthritis manifest?
Classically asymmetrical arthritis affecting IPJs Can be symmetrical involvement of small joints (rheumatoid pattern) Spinal and sacroiliac joint inflammation
63
How is psoriatic arthritis investigated?
X ray of affected joint - pencil in a cup abnormality (arthritis mutilans) MRI- sacroilitis (inflammation) Bloods - nothing as seronegative
64
How is psoriatic arthritis managed?
DMARDs - methotrexate | Avoid oral steroids
65
Why are oral steroids avoided in psoriatic arthritis?
Risk of pustular psoriasis due to skin lesions
66
What is reactive arthritis?
Sterile inflammation of the joints following infection especially urogenital, (Chlamydia) and gastrointestinal (salmonella, campylobacter)
67
What are extra articulate manifestations of reactive arthritis?
Enthesitis - tendon inflammation Skin inflammation Eye inflammation
68
What can reactive arthritis be the first manifestation of?
HIV | Hep c infection
69
What does a typical case of reactive arthritis look like?
Young adult with: - genetic predisposition (HLA-B27) - environmental trigger (salmonella)
70
How long after the initial infection does reactive arthritis occur?
1-4 weeks
71
How do we treat reactive arthritis?
NSAIDs | DMARDs if required
72
What is lupus?
A multi system autoimmune disease
73
What is systemic lupus erthymatous? SLE
Multi site inflammation; can affect any organ Often joints, skin, kidneys. Associated with autoantibodies directed against components of the cell nucleus
74
What are the clinical tests for SLE?
Antinuclear-antibodies (ANA) - high sensitivity for SLE but not specific (negative test rules out) Anti double stranded DNA antibodies (anti dsDNA Abs) - high specificity in appropriate contex

BRS 1b (25 decks)

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