Rheumato Flashcards
Sukses (26 cards)
Define RA
Rheumatoid arthritis (RA) is a systemic autoimmune condition with protean manifestations. The primary expression of disease occurs in the synovial tissues and is characterized by symmetric polyarticular inflammation, which can lead to progressive joint damage. Some of pastient has a systemic manifestation
single strongest known genetic risk factor for RA ?
HLA DRB1
Usia Puncak untuk RA
Wanita 55, LAki-laki dimulai usia 75 tahun
Pre Clinical RA
Proses autoimun bertahun-tahun mendahului manifestasi kinis yang dicerminkan dengan peningkatan faktor inflamasi misalnya CRP dan kemokin serta sitokin inflamasi, pada pasien dengan Rheumatoid factor dan anti CCP.
Radiologic Finding in RA
Periarticular osteopenia, marginal erosions, symmetric joint space narrowing in large joints
Differensial Diagnosis Utk RA
RF (+) –>
(SLE), Sjögren’s syndrome, and viral diseases, such as hepatitis
B and C, and HIV Other diseases in the
differential diagnosis include gout, particularly with tophi
mimicking the subcutaneous nodules of RA, and calcium pyrophosphate dihydrate deposition (CPPD) arthropathy,
with a pseudo-RA presentation. In elderly patients, polymyalgia
rheumatica (PMR) and remitting seronegative symmetric
synovitis with pitting edema (RS3PE) should be considered, whereas in younger patients, the signs and symptoms from parvovirus B19 infection or a postinfectious
reactive arthritis can closely parallel those of RA.
Laboratory Exams in RA
normal WBC, Anemia Normo normo, Trombositosis, normal urine Normal renal, hepatic, and other metabolic or endocrine
testing
Increased ESR (typically <50 mm/hr), and elevations CRP of similar magnitude. Both may be normal in as
many as one-third of pati nts when first seen by a
physician
• Normal serum uric acid
• RF seropositivity in approximately 70% at the time of
diagnosis; an additional 15% of patients may “seroconvert” from RF− to RF+ tatus early in the disease course
• ACPA seropositivity with a frequency approaching that observed with RF; in contrast to RF, ACPA positivity is
highly specific (>95%)
• Negative anti-nuclear antibody (ANA), although as many as 30% of patients may be positive, typically in a
low to moderate titer without positive subserologies
• Early in the disease process, radiographs are often normal, other than periarticular soft tissue swelling and evidence
of effusions in some large joints
Arthrocentesis, if performed, typically demonstrates inflammatory
synovial fluid with less than 50,000 WBC/mm3 with the proportion of polymorphonuclear (PMN) cells
typically less than 90%.
Adults Onset Still disease Cirinya
Temperature >39° C for longer than 1 week, leukocytosis >10,000/mm3 with >80% PMNs, evanescent rash, arthralgias, sore throat, lymphadenopathy, splenomegaly, liver
ysfunction, marked elevations in serum
ferritin
spondiloarthropathy
Male predominance, often oligoarticular with predominantly large joint and lower extremity distribution, low back involvement, HLA-B27+, RF/ACPA−, uveitis, other associations, including psoriasis and inflammatory
bowel disease
Vasculitis
Seronegative polyarthritis in a patient with systemic symptoms, such as fever, evidence of end-organ involvement; marked elevations in ESR or CRP; presence of anti-neutrophil cytoplasmic antibodies
RA ACR/ARA 1987 Criteria
Morning stiffnes, Lebih dari 3, Arthritis pada tangan, Simetris, Nodul Rheumatoid, serum RF dan Perubahan Radiografis ( Changes typical of RA on posteroanterior hand
and wrist radiographs, which must include
erosions or unequivocal bony decalcification localized to or most marked adjacent to
involved joints (OA changes alone do not
qualify). satu sampai empat minimal lebih dari sama dengan 6 minggu
ACR/Eular 2010 RA Criteria
Joint Involvement (0-5) RF atau RF/ACPA (0-3) CRP atau ESR (0-1) Durasi Gejala (0-1)
Faktor rpognostik
Titer antibodi Baseline aktivitas penyakit tinggi ekstraartikular durasi lama delay terapi erosi pada tulang HLADRB1 shared epitopp Faktor sosial merokok depresi dll
Definisi Remisi ACR/Eular
1 Boolean-Based Definition :
At any time point, the patient must satisfy all of the following:
Tender joint count ≤1*
Swollen joint count ≤1*
C-reactive protein ≤1 mg/dL
Patient global assessment ≤1 (on a 0-10 scale)
2. Index-Based Definition At any time point, the patient must have a Simplified Disease
Activity Index score of ≤3.3.
Key Point treatment of RA
- Rheumatoid arthritis (RA) should be diagnosed early, and disease-modifying anti-rheumatic drug (DMARD) therapy
should be initiated at the time of diagnosis. - Treatment for all patients should be based on a diseaseactivity target—either remission or low disease activity.
- The type of DMARD therapy the patient receives is not as important as ensuring that the treatment meets the disease
activity target. - The initial DMARD and the cornerstone of therapy for most patients is methotrexate.
- Many patients will require combinations of DMARDs with or without biologic agents to achieve the disease activity target.
- Many very effective biologic DMARDs are available; essentially all DMARDs are more effective when administered with methotrexate.
- Nonsteroidal anti-inflammatory drugs may provide useful symptom control but are rarely indicated without
concomitant use of DMARDs. - Glucocorticoids are rapidly effective DMARDs but have adverse effects. Therefore they should be used only with
other DMARDs and ideally only as a bridge to effective DMARD therapy. - The ubiquitous comorbidities of RA—particularly cardiovascular disease—must be addressed aggressively.
Key Point of patogenesis of SpA
- Genetics play a major role in the etiology of spondyloarthritis.
- The largest genetic contribution in the population is the B27 allele of human leukocyte antigen-B.
- TNF is a major mediator of inflammation and is currently the principle therapeutic target.
- The IL-23/IL-17 axis plays an important role in pathogenesis of spondyloarthritis.
- New bone formation as well as bone destruction occurs during the course of ankylosing spondylitis.
6.There may be a complex temporal relationship between
inflammation and new bone formation.
Karakteristik Klinis SpA
- Typical pattern of peripheral arthritis—predominantly of lower limb,asymmetric
- Absence of rheumatoid factor
- Absence of subcutaneous nodules and other extra-articular features of rheumatoid arthritis
- Overlapping extra-articular features characteristic of the group (e.g.,
anterior uveitis) - Significant familial aggregation
- Association with HLA-B27
jenis-Jenis Sp A
- Ankylosing spondylitis and nonradiograhic axial spondyloarthritis
- Reactive arthritis
- Arthropathy of inflammatory bowel disease (Crohn’s disease,
ulcerative colitis) - Psoriatic arthritis
- Juvenile chronic arthritis and juvenile-onset ankylosing spondylitis
Modified New York Criteria 1984 terkait Ankylosing Spondilitis
- L ow back pain of at least 3 months’ duration improved by
exercise and not relieved by rest - Limitation of lumbar spine in sagittal and frontal planes
- Chest expansion decreased relative to normal values for age and sex
- Bilateral sacroiliitis grade 2 to 4
5.Unilateral sacroiliitis grade 3 or 4
Definitife AS : Unilateral grade 3 or 4, or bilateral grade 2 to 4 sacroiliitis and
any clinical criterion
ASAS kriteria untuk Spa
Sacroilitis pada Imaging + 1 fitur Spa atau HLAb27 positif di tambah dua fitur SpA
Fitur SpA Inflammatory back pain Arthritis Enthesitis (heel) Uveitis Dactylitis Psoriasis Crohn’s disease/ulcerative colitis Good response to NSAIDs Family history for SpA HLA-B27 Elevated CRP* Kriteria Imaging : MRI atau Definiti Sakroilitis berdasarkan kriteria newyork 1984
Key Point of treatment in AS
NSAIDs, physiotherapy, and patient education are first-line therapy.
TNF inhibitors are effective to treat the signs and symptoms in moderate to severe disease. Biologics that target other
cytokines, such as IL-17A, also demonstrate clinical efficacy.
Some rather weak evidence supports the view that continuous use of NSAIDs may reduce radiographic progression. However, results of studies are conflicting; weighing advantages and disadvantages, it is currently unclear whether or when AS patients should be offered continuous NSAID treatment.
5 Clinical Pattern of PsA
- Asymmetric oligoarthritis
- Symmetric polyarthritis
- Predominant distal interphalangeal (DIP) joint
involvement - Predominant spondyloarthritis
- Destructive (mutilans) arthritis
Caspar Criteria Diagnosis of PsA
Inflammatory articular disease (joint, spine, or entheseal) with ≥3
points from the following:
1. Evidence of psoriasis (one of a, b, or c)
a. Current psoriasis*: psoriatic skin or scalp disease present
today as judged by a rheumatologist or dermatologist
b. Personal history of psoriasis: history of psoriasis that may be
obtained from patient, family physician, dermatologist,
rheumatologist, or other qualified health care provider
c. Family history of psoriasis: history of psoriasis in a first-degree
or second-degree relative according to patient report
2. Psoriatic nail dystrophy: typical psoriatic nail dystrophy, including
onycholysis, pitting, and hyperkeratosis observed on current
physical examination
3. Negative test for rheumatoid factor: by any method except latex,
but preferably by enzyme-linked immunosorbent assay or
nephelometry, according to the local laboratory reference range
4. Dactylitis (one of a or b)
a. Current swelling of an entire digit
b. History: history of dactylitis recorded by a rheumatologist
5. Radiologic evidence of juxta-articular new bone formation:
ill-defined ossification near joint margins (but excluding
osteophyte formation) on plain radiographs of hand or foot
Definisi Skleroderma
uncommon disease of unknown cause and complex pathogenesis. The
hallmarks of SSc are (1) autoimmunity, (2) inflammation, (3) functional and structural alterations in small blood vessels, and (4) widespread interstitial and vascular fibrosis
affecting the skin and internal organs. and chronic vascular insufficiency and widespread fibrosis cause failure
of vital organs, accounting for substantial morbidity and mortality.
