Discuss the basic epidemiology, presentation, investigation, management, complications and prognosis of rheumatoid arthritis

Question 1

Which deformity is characterised by MCP flexion, PIP hyperextension and DIP flexion?

Answer 1

Swan neck deformity

Question 2

Which human leucocyte antigen (HLA) gene is associated with rheumatoid arthritis?

Answer 2

HLA-DRB1

Question 3

What produces rheumatoid factor antibodies and anticitrullinated protein antibodies and where are they produced?

Answer 3

They are produced by activated B-cells in the synovium

Question 4

What joints are affected by rheumatoid arthritis?

Answer 4

1. shoulders
2. elbows
3. wrist
4. MCP joints
5. PIP joints
6. knees
7. ankles
8. MTP joint

Question 5

What is the Norfolk Arthritis Register?

Answer 5

A primary care based inception cohort of patients with inflammatory arthritis

Question 6

What is the classification criteria for RA?

Answer 6

At least 4 of the following for 6 weeks:

• Morning stiffness > 1 hour
• Arthritis of > 3 joint areas
• Symmetry
• Nodules
  Radiographic erosions
• Rheumatoid factor positive

Question 7

How does synovitis present upon examination?

Answer 7

• “boggy” joint swelling (similar consistency to a grape)
• the skin is usually warm and red (due to increased blood flow)
• swelling is tender to palpate

Question 8

What are Boutonniere and swan-neck deformities of the digits due to?

Answer 8

PIP synovitis and laxity and/or contraction of the extensor and flexor tendons

Question 9

What are the 4 main radiological signs of rheumatoid arthritis?

Answer 9

1. soft tissue swelling
2. periarticular osteoporosis
3. juxta-articular erosions
4. narrowing of joint space

Question 10

Name 3 categories assessed by the HAQ disability index

Answer 10

1. dressing and grooming
2. reach and grip
3. walking

Question 11

What is the pathological process behind synovitis in rheumatoid arthritis?

Answer 11

1. inflammatory cells infiltrate the synovium and proliferate
2. macrophages and osteoclasts create a layer of chronically inflamed tissue (pannus) which extends from the joint margins and erodes the articular cartilage

Question 12

True or false?

Rheumatoid arthritis affects men more than it affects women?

Answer 12

False

woman > men

2:1

Question 13

What are ligament insertions (entheses) a common site of in RA?

Answer 13

inflammation

Question 14

Which deformity is this?

Answer 14

Swan neck

Question 15

Which deformity is characterised by PIP flexion with DIP hyperextension?

Answer 15

Boutonniere

Question 16

True or false?

rheumatoid arthritis of the ankles are included in the DAS-28 score

Answer 16

False

Question 17

How can immunisation cause RA in some patients?

Answer 17

the patient has an abnormal immune system and the immunisation has acted as a trigger

Question 18

What are 4 extraarticular features of RA?

Answer 18

1. rheumatoid nodules
2. tenosynovitis
3. bursitis
4. carpal tunnel syndrome

Question 19

Which deformity is this?

Answer 19

Boutonniere

Question 20

Describe the Health Assessment Questionnaire (HAQ)

Answer 20

Total score can range from 0-3.0

higher scores indicate worse function

and greater disability

Question 21

What are 4 systemic complications of RA?

Answer 21

1. feeling systemically unwell
2. anaemia
3. felty syndrome
4. rheumatoid lung disease

Question 22

What is the societal impact of RA?

Answer 22

• within 3 years of diagnosis, 25% of patients are no longer working
• personal loss of income
• government loss of taxation
• drug costs

Question 23

What are 3 predictors of a poor prognosis?

Answer 23

1. RF/Anti-CCP
2. Nodules
3. HAQ score

Question 24

The DAS-28 (disease activity score) is a statistically derived index using:

Answer 24

1. Tender joint score
2. Swollen joint score
3. ESR
4. General health assessment

Question 25

What is most commonly affected by tenosynovitis in rheumatoid arthritis?

Answer 25

the flexor tendons of the fingers

Question 26

What is the pathological process behind joint deformity in rheumatoid arthritis?

Answer 26

1. Macrophages and osteoclasts create a layer of chronically inflamed tissue, pannus, 2. which extends from the joint margins and erodes the articular cartilage 3. extensive erosions of cartilage and bone lead to joint deformity

Question 27

What are 5 risk factors for developing rheumatoid arthritis?

Answer 27

1. cigarette smoking 2. obesity 3. immunisation 4. blood transfusion 5. previous termination of pregnancy

Question 28

What joints in the hand are spared by rheumatoid arthritis?

Answer 28

DIPs

Question 29

Is rheumatoid arthritis symmetrical or assymetrical?

Answer 29

symmetrical

Question 30

What does a positive rheumatoid factor in patients with rheumatoid arthritis?

Answer 30

a higher rate of systemic disease and poorer prognosis

Question 31

What can inflammation of the MCP joints cause?

Answer 31

Ulnar deviation

Question 32

True or false? Rheumatoid factor and anti-CCP are specific for rheumatoid arthritis?

Answer 32

False Only anti-ccp is

Question 33

What may a full blood count reveal about a patient with rheumatoid arthrits?

Answer 33

* anaemia due to chronic inflammation/disease * thrombocytosis due to chronic inflammation * CRP/ESR raised

Question 34

What are 2 surgical treatments available for RA?

Answer 34

1. arthroplasty 2. synovectomy

Question 35

What is rheumatoid arthritis?

Answer 35

an autoimmune inflammatory condition characterised by a symmetrical polyarthritis

Question 36

True or false? RA affects mainly small and medium sized joints in a symmetrical fashion

Answer 36

True

Question 37

What imaging technique can be used to detect synovitis in early rheumatoid arthritis?

Answer 37

ultrasound

Question 38

What are rheumatoid nodules?

Answer 38

* firm subcutaneous nodules * which develop in areas affected by pressure or friction

Question 39

What causes the thickened joint capsule to extend in RA?

Answer 39

effusion

Question 40

What immunological cells play a key role in initiating inflammation in rheumatoid arthritis? (3)

Answer 40

1. T-lymphocytes 2. B-cells 3. activated macrophages