Rheumatoid Arthritis

Question 1

What are the two immunogenetic markers (major histocompatability comples types) commonly seen in patients with rheumatoid arthritis?

Answer 1

HLA-DR4 or HLA-DR1

Question 2

What are the diseases where rheumatoid factor can be detected?

Answer 2

primary Sjӧgren syn, SLE, cryoglobulinemia, hepatitis C, and systemic vasculitis

Question 3

What is the antibody present at the onset of rheumatoid arthritis?

Answer 3

Anti-cyclic citrullinated peptide antibodies (anti-CCP)

Question 4

When anti-CCP Ab’s are in high titer, what is it indicative of in RA?

Answer 4

Progressive erosive disease

Question 5

What joints are involved with RA?

Answer 5

metacarpophalangeal, proximal interphalangeal, wrist, and metatarsophalangeal joints

Question 6

What are the clinical presentations of RA?

Answer 6

Patients describe deep aching and soreness in the involved joints, which are aggravated by use and can be present at rest.
Hallmarks of RA in joints: stiffness, heat redness, soft tissue swelling, pain, dysfunction

Question 7

What are constitutional features of rheumatoid arthritis?

Answer 7

Fatigue, weight loss, muscle pain, excessive sweating, or low-grade fever may be reported by patients presenting w/ RA; most patients w/ active arthritis have more than 1 hr of morning stiffness

Question 8

How can involvement of the cervical spine be used to Dx RA?

Answer 8

50% of all patients with chronic RA have radiographic involvement of the AA joint; this is diagnosed from cervical flexion and extension radiographs showing subluxation

Question 9

What are the symptoms associated with cervical spine involvement in a patient with rheumatoid arthritis

Answer 9

pain and stiffness in the neck, drop attacks, hand weakness, interference with blood flow with the vertebral arteries causes the neurological Sx

Question 10

What are the indications for surgical treatment in a patient with cervical spine rheumatoid arthritis?

Answer 10

neurologic or vascular compromise and intractable pain

Question 11

What is the presentation of tenosynovitis?

Answer 11

diffuse swelling between the joints and a palpable grating within the flexor tendon sheaths in the palm with passive movement of the digit

Question 12

What are the 1st and 2nd most common etiologies for carpal tunnel syndrome (CTS)?

Answer 12

Rheumatoid arthritis and inflammatory arthritis

Question 13

What are the initial Sx of CTS?

Answer 13

Pts will present with paresthesias of the hand in a typical median nerve distribution with the discomfort radiating up the forearm or into the upper arm.
Symptoms worsen at night due to prolonged flexion of the wrist

Question 14

What are the late Sx of CTS?

Answer 14

thenar muscle weakness and atrophy and permanent sensory loss.

Question 15

What is the Tx of CTS?

Answer 15

resting splints, control of inflammation, and local injection of glucocorticosteriod

Question 16

What is the clinical presentation of boutonniere deformity?

Answer 16

hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint

Question 17

What is the clinical presentation of swan-neck deformity?

Answer 17

hyperextension at the proximal interphalangeal joint and flexion of the distal interphalangeal joint

Question 18

What is the clinical presentation of ulnar deviation of the MP joints?

Answer 18

can progress to complete volar subluxtion of the proximal phalanx from the metacarpophalangeal head

Question 19

Where might rheumatoid nodule be located?

Answer 19

over extensor surfaces and at pressure points; rare in the lungs, heart, sclera, and dura mater

Question 20

How might rheumatoid nodules cause death?

Answer 20

Breakdown of the skin over rheumatoid nodules, with ulcers and infection, can be a major source of morbidity.
The infection can spread to local bursae, infect bone, or spread hematogenously to joints

Question 21

who is at risk for rheumatoid vasculitis?

Answer 21

Rheumatoid vasculitis usually occurs in persons with severe, deforming arthritis and a high titer of rheumatoid factor

Question 22

What happens in obliterative enarteropathy?

Answer 22

Proliferation of the vascular intima and media causes this obliterative endarteropathy, which has little associated inflammation

Question 23

What happens in leukocytoclastic (small cell) vasculitis?

Answer 23

produces palpable purpura or cutaneous ulceration, particularly over the malleoli of the lower extremeties.

Question 24

What shows with the the pleural fluid seen in rheumatoid pleural effusions?

Answer 24

The pleural fluid is an exudate with a concentration of glucose that is low (10-50 mg/dL) because of impaired transport of glucose into the pleural space.

Question 25

What are the pulmonary nodules seen in rheumatoid arthritis?

Answer 25

Pulmonary nodules appear singly or in clusters; the single nodules have the appearance of a coin lesion. Nodules typically are pleural-based and may cavitate and create a bronchopleural fistula.

Question 26

What are the physical findings of interstital fibrosis?

Answer 26

diffuse dry crackles on lung auscultation and a reticular nodular radiographic pattern affecting both lung fields, initially in the lung bases.

Question 27

What is the imaging modality used to differentiate between the interstitial rheumatoid lung syndromes?

Answer 27

high resolution CT

Question 28

What might recurrent effusive pericarditis evolve into?

Answer 28

chronic constrictive pericarditis

Question 29

What are the presenting manifestations of recurrent effusive pericarditis?

Answer 29

unexplained edema or ascites

Question 30

What is the mortality and Tx of recurrent effusive pericarditis?

Answer 30

Untreated constrictive pericarditis has a very high 1-year mortality of 70%. It will not respond to medical therapies therefore surgical pericardiectomy is necessary.

Question 31

Which lab abnormalities indicate liver impairment in rheumatoid arthritis?

Answer 31

increased levels of liver enzymes, particularly alkaline phosphatese, aspartate aminotransferase, γ- glutamyltransferase, and acute-phase proteins and hypoalbuminemia

Question 32

What is the most common ophthalmic complication of rheumatoid arthritis?

Answer 32

Keratoconjunctivits sicca, or secondary Sjӧgren syndrome

Question 33

What are the common lab abnormalities seen in rheumatoid arthritis patients?

Answer 33

, normocytic anemia (hemoglobin value about 10 g/dL), leukocytosis, thrombocytosis, hypoalbuminemia and hypergammaglobulinemia are common

Question 34

What is the frequency of a positive rheumatoid factor and when its presence is detectable?

Answer 34

Rheumatoid factor (IgM) occurs in 90% of patients, but its presence may not be detected for months after the initial joint symptoms occur

Question 35

What are the four diseases which are most likely to have a high-titer rheumatoid factor?

Answer 35

Rheumatoid arthritis, Sjӧgren syndrome, Mixed cryoglobulinemia, and subacute bacterial endocarditis

Question 36

What is the antibody which is more specific for rheumatoid arthritis and may be present when rheumatoid factor is absent?

Answer 36

Anti-CCP antibodies

Question 37

What is the presentation of the synovial fluid associated with rheumatoid arthritis?

Answer 37

is cloudy and light yellow, has poor viscosity, and typically contains 10,000 to 75,000 leukocytes/mcL, predominantly neutrophils

Question 38

What are the radiographic findings in early RA?

Answer 38

radiographic findings are normal or show soft tissue swelling and periarticular osteopenia

Question 39

What are the radiographic findings in later stage RA?

Answer 39

haracteristic changes of periarticular osteoporosis, symmetric narrowing of the joint space, and marginal bony erosions become obvious; most common in the hands and forefeet

Question 40

What are the radiographic findings in end stage RA?

Answer 40

subluxtion and other deformities, joint destruction, fibrous ankylosis, and bony ankylosis.

Question 41

What are the American Rheumatism Association criteria for diagnosing rheumatoid arthritis?

Answer 41

One or more hours of morning stiffness in and around the joints Arthritis of 3 or more joint areas involved simultaneously Arthritis of at least 1 area in the wrist, metacarpophalangeal or proximal interphalangeal joints Symmetric arthritis involving the same joint areas on both sides of the body Rheumatoid nodules Serum rheumatoid factor Radiographic changes typical of rheumatoid arthritis, including periarticular osteoporosis, joint-space narrowing, and marginal erosions.

Question 42

Who are the patients that are at high risk of early disability from rheumatoid arthritis?

Answer 42

Patients who experience a persisting polyarthritis with increased acute-phase reactants and a positive rheumatoid factor or anti-CCP antibody are at high risk for early erosive disease within 1 to 2 years of symptom onset and early disability

Question 43

What is the initial medication used in the treatment of rheumatoid arthritis?

Answer 43

NSAID

Question 44

What is the role of disease-modifying agents of rheumatic disease (DMARDs) in the treatment of rheumatoid arthritis?

Answer 44

The goal of DMARD therapy is to slow disease progression (erosive damage) and maintain joint function

Question 45

What are the ten DMARD agents?

Answer 45

Methotrexate, hydroxychloroquine, sulfasalazine, minocycline, leflunomide, cyclosporine, azathioprine, anti-cytokine therapies (including anti-tumor necrosis factor, IL-6 and IL-1 inhibitors), rituximab, and abatacept

Question 46

When should DMARD therapy start?

Answer 46

Therapy with DMARD should be started early once RA is diagnosed

Question 47

How long should DMARD therapy last?

Answer 47

Uninterrupted treatment with a disease-modifying agent for 3-6 months is usually to assess its effect. Combination DMARD therapy have come more common because it has shown enhanced benefits especially when it includes methotrexate.

Question 48

What is the use of surgery in the treatment of rheumatoid arthritis?

Answer 48

Synovectomy of the wrist and nearby tendon sheaths is beneficial when medications are not working; this operation preserves joint function and prevents lysis of extensor tendons that can result in a loss of function.

Question 49

What is the indication for arthroplasty in rheumatoid arthritis?

Answer 49

Arthroplasty is reserved for patients in whom medical management has failed and in whom intractable pain or compromise in function developed because of a destroyed joint. Joint replacement has had a major impact on reducing patient disability.