Reactive and rheumatoid arthritis

Question 1

What is arthritis

Answer 1

‘catch all’ term for joint disease/inflammation
There are different types

Question 2

what are the different types of arthritis

Answer 2

infectious
inflammatory
degenerative
rheumatologic
etc

Question 3

What is arthritis usually associated with

Answer 3

bony changes such as osteophytes or cartilage loss

Question 4

What is reactive arthritis also known as

Answer 4

Reiter’s syndrome

Question 5

what is Reactive arthritis

Answer 5

asymmetric ologoarthritis (2-4 joints) precipitated by infection

most often involved the LE joints and associated with extra-articular manifestations

Question 6

what is the typical presentation of patient with reactive arthritis

Answer 6

M>F (9:1)
average: 20-40 yo
50-80% of patient are HLA-B27 positive
caucasian >
+FH of reactive arthritis increases risk

Question 7

What is the pathophysiology of reactive arthritis

Answer 7

most commonly secondary to GI/GU infection - exact bacterial pathogenesis unclear

Question 8

what are the common GI pathogens that can cause reactive arthritis

Answer 8

Shigella
Salmonella
Yersinia
Campylobacter

Question 9

What are the common GU pathogens that can cause reactive arthritis

Answer 9

chlamydia tachomatis
ureaplasma urealyticum

Question 10

what is the presentation of a patient with Reactive arthritis

Answer 10

Asymmetric oligoarthritis
predominantly affects the LE joints (Knees and ankle most common)

joint stiffness/decreased ROM
joint effusion
joint tenderness

Question 11

What are some co-accuring signs of reactive arthritis

Answer 11

Enthesitisi (inflammation at tendon/ligament attachments)
Dactylitisi (sausage bigits)
Mucocutaneous lesions - painless oral ulcers, circinate balanitis, urethritis/cervicitis

Question 12

What are the occular symptoms associated with reactive arthritis

Answer 12

conjunctivitis, anterior uvelitis, iritis, scleritis, episcleritis, keratitis (cornea)

Question 13

What are the cardiac manifestations of reactive arthritis

Answer 13

aortitis, valvular involvement, heart block

Question 14

What is the typical presentation for reactive arthritis

Answer 14

Cant see, cant pee, cant climb a tree, cant have sex with me

conjunctivitis, urethritis, arthritis, GU infection

Question 15

How is reactive arthritis worked up?

Answer 15

clinical diagnosis - no specific lab test
supportive diagnostics:
synovial fluid - inflammatory, Elevated ESR/CRP, RF negative

ID causative agent: urine culture, stool testing, STI screen, blood cultures

Question 16

What is the treatment of reactive arthritis

Answer 16

infections need to be properly treated - reactive arthritis will decrease with timely treatment of STI

mainstay: NSAIDS - high dose, continuous
Second line: intra-articular or systemic steroids
if persistant: sulfasalazine or MTX

Question 17

What is psoriatic arthritis?

Answer 17

inflammatory arthritis secondary to psoriasis

Question 18

what is the typical population for psoriatic arthritis

Answer 18

affects 5-20% of patients with psoriasis (M=F), average age 30-55
5x more common in those with severe skin symptoms vs mild
50% have positive HLA- B27

Question 19

What are the five different disease patterns for psoriatic arthritis

Answer 19

1. symmetric polyarthritis
2. asymmetric mono-or oligoarthritis
3. monoarthritis of the DIP (often with nail pitting and onycholysis)
4. axial arthritis - sacroiliitis and spinal involvement (strong association with HLA-B27)
5. arthritis mutilans (severe, widespread and results in deformity)

Question 20

what is the typical presentation of psoriatic arthritis

Answer 20

primarily involve the hands and feet but also knees and hips
dactylitis (sausage digits)
Nail pitting
onycholysis
enthesitis
ocular inflammation

Question 21

How is psoriatic arthritis worked up?

Answer 21

x-ray is the preferred imaging and is useful for differentiation between other arthritides

erosion of the articular surface and surrounding bone in the DIP and PIP
Arthritis mutlians - opera glass hands, telescoping

Question 22

What are the supportive diagnostics for psoriatic arthritis

Answer 22

synovial fluid - inflammatory (elevated WBC, PMN% and negative gram stain and culture)
Elevated ESR/CRP
RF negative but may have false positive

Question 23

What is the first line treatment for psoriatic arthritis

Answer 23

Biologic DMARDs
- TNF-alpha inhibitors/monoclonal antibodies (entanercept, infliximab, adalimumab)

Question 24

What are other treatment options for psoriatic arthritis

Answer 24

NSAIDS (high dose, consistent administration)
Non-biologic DMARDs (methotrexate, sulfasalazine, hydrochloroqine)

Question 25

What medications are not helpful for the treatment of PsA

Answer 25

Corticosteroids are not effective in PsA and may precipitate pustular psoriasis during tapers

Question 26

What is Rheumatoid arthritis

Answer 26

inflammatory symmetric polyarthritis - chronic disease inflammation of synovial membrane - synovitis ad proliferation which leads to progressive joint damage and deformity

Question 27

what is the average onset of rheumatoid arthritis in women vs men

Answer 27

women: 30-50 Men: 50-70

Question 28

what are risk for the development of developing RA

Answer 28

strong genetic association - HLA-DR most strongly associated smoking and periodontitis increase risk F>M

Question 29

What are the joint involvement/ presentation of RA?

Answer 29

includes articular and extra-articular manifestations articular symptoms - usually occur over weeks - months small joints affected (PIP, MCP, MTP, TMJ) - SPARES THE DIP AND THORACIC LUMBAR SPINE involves larger joints later (wrist, knees, elbows, ankles, hips, shoulders)

Question 30

What are the articular symtpoms associated with RA

Answer 30

hands and wrists involved in almost all patients late stage associated with gross deformities, and loss of function

Question 31

what are the extra-articular symptoms?

Answer 31

most seropositive for RF or ACPA Rheumatoid nodules (20%) Dryness of eyes, mouth, mucous membranes scleritis, episcleritis, keratitis interstitial lung disease, pericarditis, vasculitis

Question 32

What are the preferred diagnostic test for RA?

Answer 32

x-rays are first line imagine often normal early on (first 6 months or so) supportive findings: osteopenia, Juxta-articular erosions, symmetric joint degenerations

Question 33

what labratory findings are used for RA

Answer 33

presence of Anti-CCP antibodies (anti-cyclic citrullinated peptide antibodies) - most sensitive and specific + RF or + ANA most have elevated ERS/CRP May also see CBC abnormalities (anemia, elevated platelet count during flare, normal or elevated WBC count) synovial fluid inflammatory

Question 34

What is ACPA

Answer 34

anti-CCP (anti-cyclic citrullinated peptide antiboties)

Question 35

What are the differential diagnosis for RA?

Answer 35

OA Gout Septic arthritis Vital syndromes PsA, active arthritis gout/pseudogout SLE plymyalgia rheumatica paraneoplastic syndromes scarcoidosis lyme disease

Question 36

what is the mainstay treatment of RA

Answer 36

DMARDS (TNF inhibitors) reduce inflammation and pain joint preservation and eformity prevention - irreversible once present should be started as early as possible systemic corticosteroids often started first until DMARDs take effect

Question 37

What are the other treatment options for RA

Answer 37

non-biologics MTX (first line) Sulfasalazine or Hydroxychloroquine (second line) other options: leflunomide, tofacitinib, minocycline

Question 38

What is the prognosis for RA

Answer 38

it is associated with increased mortality risk - 8 years earlier for Males and 10 years earlier for Females (associated with CVD) RA also confer increased risk for osteoporosis, lymphoma and infections 50% or more RA patient have to stop worked after 5-10 years

Question 39

what are the subtypes of juvenile idiopathic arthritis

Answer 39

oligoarticular seronegative polyarticular seropositive polyarticular systemic psoriatic enthesis-related

Question 40

which type of juvenile idiopathic arthritis is most common

Answer 40

most common subtype four or less joints affected F>M kids 1-7yo asymmetric arthritis need regular eye exams

Question 41

What are important factors of seropositive polyarticular JIA

Answer 41

5 or more joint affected RF positive teenage girls - of color more susceptible symmetric arthritis

Question 42

what are important factors of seronegative polyarticular JIA

Answer 42

five or more joints symmetric or asymmetric younger children, peask in ages 1-3, and agan later in teens F>M Negative RF at onset but can transition to seropositive (+ RF)

Question 43

what are important factors of systemic JIA

Answer 43

variable number of joints males = females peaks about 2yo WITH FEVER AND SALMON COLORED RASH Must rule out malignancy/infection macrophage activation syndrome - potentially life threatening complication , very high serium ferritin

Question 44

what are important factors of psoriatic JIA

Answer 44

looks like adult PsA - one or more joints involved psoriatic rash OR + FH of psoriasis

Question 45

What are important factors of Enthesitis-Related JIA

Answer 45

pain and stiffness at tendon/ligament attachement sites LE MALES 8-12 elevated ESR/CRP associated with HLA-B27

Question 46

What is the workup for any JIA

Answer 46

diagnosis of exlusion - no specific lab tests, need to rule out infection, malignancies and other rheumatologic diseases CBC, ESR/CRP, LFTS and renal function tests,, ANA and RF, HLA-B27 Radiographs used to rule out other joint pathology but usually normal

Question 47

what is the tx for JIA

Answer 47

initiated early to control symptoms and prevent disability/deformity 1/2 need to continue treatment into adulthood First line: NSAID and corticosteroids If continued symtoms: start DMARDS - MTX if seropositive: DMARDS to start