Intro To Rheum P2

Question 1

What are the two ways you can classify joint?

Answer 1

Either by structure or function

Question 2

What are the three different types of joints using structural classification?

Answer 2

Fibrous joints
Cartilaginous joints
Synovial joints

Question 3

What are fibrous joints?

Answer 3

No space between the bones for example sutures in the skull

Question 4

What are cartilaginous joints and an example?

Answer 4

Joints in which the bones are connected by cartilage such as in the spine

Question 5

What are synovial joints and an example?

Answer 5

Joints Which have a space between the adjoining bones and the space is filled with synovial Fluid
E.g knees

Question 6

What 3 categories can joints be classified into based of function?

Answer 6

Synarthroses (no movement)
Amphiarthroses (limited movement)
Diarthroses(free movement)

Question 7

What does Synarthroses mean?

Answer 7

No movement joints

Question 8

What does Amphiarthroses mean?

Answer 8

Limited movement of joints

Question 9

What does Diarthroses mean?

Answer 9

Free movement of the joint

Question 10

What is this?

Answer 10

Synovium membrane

Question 11

What is this?

Answer 11

Articular cartilage

Question 12

What is this?

Answer 12

Joint cavity containing synovial fluid

Question 13

What does the Synovium contain

Answer 13

Type one collagen
Type A &B synoviocytes

Question 14

What does articular cartilage contain?

Answer 14

Type 2 collagen
Aggrecan

Question 15

What is cartilage composed of?

Answer 15

Chondrocytes and extracellular matrix

Question 16

What is the most relevant proteoglycan present in Cartilage?

Answer 16

Aggrecan

Question 17

What are the three main categories of autoimmune arthritis?

Answer 17

Rheumatoid arthritis
Seronegative arthritis
lupus and related disorders

Question 18

What extra articular diseases can occur in rheumatoid arthritis?

Answer 18

Subcutaneous nodules
Lung disease
Ocular inflammation
Vasculitis
Neuropathies
Felty’s syndrome

Question 19

What does this image show and what condition shows this feature?

Answer 19

Episcleritis seen in rheumatoid arthritis

Question 20

What is feltys syndrome?

Answer 20

A rare condition characterised by the triad of splenomegaly, leukopenia and RA

Question 21

What is splenomegaly?

Answer 21

Enlarged spleen

Question 22

What does this image show?

Answer 22

Rheumatoid/subcutaneous nodules

Question 23

What do subcutaneous/rheumatoid nodules contain?

Answer 23

Central area of fibrinoid necrosis (dead tissue) surrounded by histiocytes (macrophages)

Question 24

Describe the pathogenesis of rheumatoid arthritis?

Answer 24

• in RA, elevated TNF- alpha levels
• causes neovascularisation lymphangiogenesis + production of inflammatory cells
• Synovium = inflamed
• It proliferates it form a mass of tissue = pannus 

Question 25

What factors cause the synovium to proliferate and form a pannus?

Answer 25

Neovascularisation (in growth of new blood vessels) Lymph angiogenesis Inflammatory cells

Question 26

What is the dominant cytokine in rheumatoid arthritis?

Answer 26

TNFa (tumour necrosis factor -alpha)

Question 27

What does TNF-a do in RA?

Answer 27

Bone erosion Pain,joint swelling Joint space narrowing

Question 28

What would the blood test findings be in a px with RA (Hb, MCV, WCC, PLT, ESR, CRP)?

Answer 28

Question 29

What 2 auto antibodies are seen in RA?

Answer 29

Rheumatoid factor Antibodies to citrullinated proteins antigens (ACPA)

Question 30

How do we detect rheumatoid factor?

Answer 30

Use IgM antibodies against that recognise the Fc portion of IgG (autoantibody) Essentially use an antibody against an antibody

Question 31

Why is the presence of rheumatoid factor only indicative of rheumatoid arthritis not diagnostic?

Answer 31

Has a very low specificity If px has negative result def doesn’t have RA BUT if has positive, may not necessarily have it

Question 32

What is citrullination? 

Answer 32

A type of post-transcriptional modification where AA arginine is converted into AA citrulline

Question 33

What enzyme mediates the citrullination of peptides?

Answer 33

Peptidyl arginine deiminases

Question 34

Why is the presence of CCP a useful marker of RA?

Answer 34

It’s highly specific, hence if you have it you are very likely to have rheumatoid arthritis

Question 35

What 3 imaging techniques can you do in RA?

Answer 35

X-ray Ultrasound MRI

Question 36

How useful are X rays in diagnosing RA?

Answer 36

Can only see severe forms of RA with X Ray Harder to pick up early stages of RA

Question 37

How useful is an ultrasound detecting rheumatoid arthritis?

Answer 37

V good at picking up earlier stages of condition Can see: Synovial hypertrophy, Increased blood flow and erosions

Question 38

What is a Doppler signal and how does this relate to RA?

Answer 38

Shows blood flow through tissue during ultrasound. Seen in early stages of RA

Question 39

What are the 3 main groups of medication RA patients can use?

Answer 39

Glucocorticoids (steroids) NSAIDs DMARDS (disease modifying anti rheumatic drugs)

Question 40

Why are steroids used in rheumatoid arthritis?

Answer 40

Reduce inflammation but only used in short term

Question 41

Why are steroids only used in the short term and what major condition can it lead to?

Answer 41

Have really bad side effects such as Cushing syndrome

Question 42

What is the 1st line treatment regime of RA

Answer 42

short course of steroids DMARD (methotrexate & another one)

Question 43

What is the main DMARD used in RA?

Answer 43

methotrexate

Question 44

How does methotrexate work?

Answer 44

Inhibits dihydrofolate reductase Is immunosuppressive

Question 45

What is the 2nd line treatment regime for RA

Answer 45

biologicals such as anti-TNF-a

Question 46

What do DMARDS tend to be

Answer 46

Immunosuppressive

Question 47

What are biological therapies?

Answer 47

Proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

Question 48

What are 4 things biological therapies can target to treat RA?

Answer 48

1. Inhibit TNF-a 2. Deplete B cell 3. Modulation of T cell costimulation 4. Inhibit IL-6 signalling

Question 49

What does the ‘seronegative’ mean in seronegative arthritis?

Answer 49

Blood doesn’t have rheumatoid factor or CCP, but patient still has arthritis

Question 50

What is psoriatic athritis?

Answer 50

Arthritis that occurs when you have psoriasis

Question 51

Is rheumatoid factor present in psoriatic arthritis?

Answer 51

No - it’s a seronegative arthritis

Question 52

What are some of the clinical presentations of psoriatic arthritis?

Answer 52

Varied clinical presentations, but classically asymmetrical arthritis affecting interphalangeal joints

Question 53

What is reactive arthritis?

Answer 53

Sterile inflammation in joints following infection elsewhere in the body

Question 54

What are the common infections that cause reactive arthritis?

Answer 54

Urogenital Gastrointestinal HIV Hep C

Question 55

What are some important extra-articular manifestations of reactive arthritis?

Answer 55

Enthesitis (tendon inflammation) Skin inflammation Eye inflammation

Question 56

What type of arthritis is seen as a manifestation of HIV or HEP C infection?

Answer 56

Reactive arthritis

Question 57

Which HLA makes you more predisposed to reactive arthritis?

Answer 57

HLA -B27

Question 58

How long after infection does reactive arthritis symptoms begin to show?

Answer 58

1-4 weeks post infection

Question 59

What is inflammatory spondyloarthritis?

Answer 59

Inflammation of spine and sacroiliac joints Peripheral joints such as entheses an also be affected

Question 60

What is a classical example of inflammatory spondyloarthritis?

Answer 60

Ankylosing spondylitis

Question 61

What are the the extra articular manifestations of inflammatory spondyloarthritis? (4 A’s)

Answer 61

Anterior uveitis Apical lung fibrosis Aortitis Amyloidosis

Question 62

What does this image show and which type of arthritis is this seen in?

Answer 62

Anterior uveitis Seen in inflammatory spondyloarthritis

Question 63

What is ankylosing spondylitis characterised by?

Answer 63

Enthesitis (inflammation of the entheses - where tendon/ligament join to bone)

Question 64

Which HLA gene is strongly associated with ankylosing spondylitis?

Answer 64

HLA-B27

Question 65

What 3 cytokines have a key role in the pathophysiology of ankylosing spondylitis?

Answer 65

TNF-A IL-17 IL-23

Question 66

What is a key clinical feature of ankylosing spondylitis?

Answer 66

Loss of spinal movement

Question 67

What happens if ankylosing spondylitis is left untreated

Answer 67

Spinal Enthesitis -> bone growths between vertebrae -> spinal fusion -> loss of spinal movement

Question 68

What sign does this MRI show and what condition is this ?

Answer 68

Shiny corners - seen in ankylosing spondylitis

Question 69

How is ankylosing spondylitis managed?

Answer 69

Combination of physiotherapy and Pharmolologicals

Question 70

What are the 1st line drugs used in ankylosing spondylitis?

Answer 70

NSAIDS

Question 71

what is the mechanism of action of NSAIDS

Answer 71

inhibits COX 1 &2 hence inhibits prostaglandin production, reducing inflammation and pain

Question 72

What are some key side effects of NSAIDS

Answer 72

Peptic ulcers and asthma exacerbation

Question 73

Why is asthma exacerbated by NSAIDS.?

Answer 73

As NSAIDs inhibit conversation of arachidonic acid into prostaglandins, more arachidonic acid is converted into leukotrienes which causes bronchoconstriction

Question 74

What is the 2nd line treatment option for ankylosing spondylitis?

Answer 74

Biological therapies

Question 75

What are the biological therapies used in treating ankylosing spondylitis ?

Answer 75

Monoclonal antibodies Anti-TNF-A Anti-IL17

Question 76

What is lupus (sle)

Answer 76

A multi-system autoimmune disease

Question 77

Which organ is particularly affected by SLE?

Answer 77

Kidneys, leads to renal failure

Question 78

What clinical tests can be used to diagnose SLE

Answer 78

usually detect autoantibodies such as: Antinuclear antibodies Anti double stranded DNA antibodies

Question 79

What type of rash is this and in which condition do you commonly see this in?

Answer 79

Malar/ butterfly rash seen in SLE