ICL 8.7: Rheumatoid Arthritis Flashcards
(39 cards)
what’s the hallmark of RA?
symmetric synovial proliferation and tenderness in multiple joints, particularly the small joints of the hands and feet
most patients experience joint stiffness or gelling for more than an hour in the morning
what marker is related to RA?
the blood of approximately 80% of patients with RA contains rheumatoidfactor (RF)
this is an immunoglobulin that binds the Fc region of the IgG molecule, anti–citrullinated peptide antibodies (ACPAs), or both RF and ACPAs
what is the strongest environment risk factor for RA?
Cigarette smoking remains the strongest environmental risk factor for RA
other lifestyle factors and exposures such as alcohol use may be inversely associated with RA
what is RA?
a systemic autoimmune disease characterized by the presence of autoantibodies in peripheral blood and synovial fluid. Most autoantibodies are not directed to joint-specific antigens
a common autoimmune disease that is associated with progressive disability, systemic complications, early death, and socioeconomic costs
RA involves a complex interplay among genotype, environmental triggers, and chance
localization of the inflammatory response occurs in the joint by virtue of poorly understood mechanisms that probably involve microvascular, neurologic, biomechanical, or other tissue-specific pathways
what is the genetic role in RA?
twin studies implicate genetic factors in rheumatoid arthritis,with concordance rates of 15 to 30% among monozygotic twins and 5% among dizygotic twins
what is the environmental role in RA?
gene interactions described in the text promote loss of tolerance to self-proteins that contain a citrulline residue, which is generated by post-translational modification
this anticitrulline response can be detected in T-cell and B-cell compartments and is probably initiated in secondary lymphoid tissues or bone marrow
these events generate an autoimmune response to citrulline-containing self-proteins
the localization of the inflammatory response occurs in the joint by virtue of poorly understood mechanisms that probably involve microvascular, neurologic, biomechanical, or other tissue-specific pathways.
what is the pathogenesis of RA?
synovitis is initiated and perpetuated by positive feedback loops and in turn promotes systemic disorders that make up the syndrome of rheumatoid arthritis
it’s a combination of environmental factors, epigenetic modifications and susceptibility genes that lead to altered post-transcriptional regulation and loss of tolerance that leads to autoimmune disease and arthritis
what is synovitis?
inflammation of a synovial membrane that lines the joints
this is the hallmark of RA!!
synovial tissue in joints with RA is markedly expanded by the recruitment and retention of inflammatory cells along with the formation of villus projections and the generation of pannus tissue that invades and destroys cartilage and bone
45 year old female with history of Rheumatoid Arthritis came to her Rheumatologist for follow up. She is maintained on methotrexate 15 mg and folic acid. She denies any joint pain or stiffness. Her vitals are stable. On exam, she has no joint tenderness or swelling. On her elbow, she has firm mobile nodule which is painless. It does not interfere with her activity. Nodule was biopsied.
What will you see in pathology?
focal central fibrinoid necrosis with surrounding fibroblasts
aka a rheumatoid nodule!
what are the stages of RA?
genetic risk –> preclinical autoimmunity –> initial signs/symptoms –> classifiable clinical disease
the clinical course of RA follows an onset of disease that may be abrupt and acute, gradual and insidious, or subacute between these extremes
a gradual onset is most common (at least 50% of cases), whereas a sudden onset is much less common (10% to 25%)
RA begins predominantly as an articular disease, and one or many joints may be affected.
what happens during the preclinical stage of RA?
the preclinical period is present for a substantial time before the onset of clinically apparent inflammatory arthritis
it’s characterized by the evolution of multiple autoimmune and inflammatory processes that are measured by a number of specific biomarkers
it’s when a patient with susceptibility gene is exposed to environmental factors which leads to the development of autoimmunity and antibody production
when this is exposed to risk factors will lead to damage of cartilage and inflammation
which joints are most often effected by RA?
- PIP
- MCP
- wrist
- elbow
- shoulder
- hip
- knee
- ankle
how do you assess TA?
4 point technique
what aerate 2 deformities you can see with RA?
- boutonnere = PIP flexing
2. swan neck deformity = PIP extension and DIP flexion
which joints are effected with osteoarthritis?
- neck
- lumbar spine
- hips
- knees
- DIP and PIP
MCP and MTP joints are NOT involved like in RA
go look at diagram
what are the extra-articular manifestations of RA?
these are poor prognostic factors; especially vasculitis and rheumatoid lung disease
- pericarditis
- pleuritis
- vasculitis
- Sojern syndrom
- RA nodules
although the onset of RA is predominantly articular, it is frequently associated with a variety of extraarticular features, including generalized weakness, anorexia, weight loss, or fever
what are rheumatoid nodules?
they develop on pressure areas like elbows, finger joints, occipital scalp, achilles tendon
they are firm and can be seen on tendons and frequently adherent to the underlying periosteum
what is Sweet syndrome?
spots on the skin from RA
its main signs include fever and painful skin lesions that appear mostly on your arms, neck, head and trunk
what is pyoderma gangrenosum?
not limited to RA but it’s a skin condition where
what are the hematological manifestations of RA?
- anemia
due to reduced EPO and blunted response to EPO; usually correlates to disease stage
- thrombocytosis
may correlate with the number of joints involved
- lymphadenopathy
60 year old male with history of seropositive [ RF and CCP] Rheumatoid Arthritis came with ℅ fever and fatigue. He has long standing Rheumatoid Arthritis for which he is non compliant to medication. He has left lower extremity ulcer which is non healing. He has Rheumatoid nodule on his right elbow. Temp: 100.5 Pulse 90, BP- 120/70. On Physical Exam he has symmetrical synovitis of his b/l MCP and MTP. Respiratory: clear. Abdomen: Non tender, BS+, Fullness in LUQ.
Labs:
WBC: 1800 , Hb : 11.5 GM, Platelets: 450
what’s the diagnosis?
felty’s syndrome
what is felty’s syndrome?
RA + splenomegaly + leukopenia
it occurs in patients with long standing, seropositive, nodular, deforming RA
bacteria infections are common in Felty syndrome and correlated with a polymorphonuclear leukocyte count lower than 100 = high mortality
increase in number of large granular lymphocytes in blood and bone marrow
SANTA = splenomegaly – anemia — neutropenia – thrombocytopenia — arthritis
what are the lung manifestation of RA?
- pleural effusion
the presence of multinucleated giant cells is highly specific for rheumatoid pleuritis
- pulmonary nodules
- RA interstitial lung disease
generally takes the form of nonspecific interstitial pneumonitis or usual interstitial pneumonitis
what is Caplan’s syndrome?
pulmonary nodulosis and pneumoconiosis in patients with RA
it’s characterized by several nodules greater than 1 cm in diameter and scattered throughout peripheral lungs
seen in patients exposed to coal dust
