Rheumatoid Arthritis, Juvenile Idiopathic Arthritis Flashcards
(12 cards)
Rheumatoid Arthritis overview
what age and gender
A chronic systemic autoimmune disease
Susceptibility genes; HLA-DR1, HLA-DR4
Prevalence is 1% of population.
Women 30-40 y.o. > Men 50-60 y.o.***
Hyperplastic synovial tissue leads to T-cell mediated joint destruction.
Characterized by:
Symmetric polyarthritis
Cartilage destruction & bone erosion
Loss of joint structure (joint deformities)
Rheumatoid Arthritis
Signs & Symptoms
- Insidious joint pain, stiffness and swelling
- MORNING STIFFNESS lasting >30 min & pain
- Decreased ROM
- symmetrical polyarthritis of small joints of the hand and feet -> ulnar deviation of hand, swan neck and boutonniere deformites, nodules
- -Spares the DIP
- tender, soft boggy warm effusion of the inflammed joints
Systemic symptoms:
* Fatigue
* Fever
* Weight loss
* Anorexia
Inflammatory cytokines affect multiple organ systems:
* Skeletal muscle -> protein breakdown
* Skin -> Rheumatoid nodules
* Blood -> atheromatous plaques
* Brain -> fever
* Lung -> scar tissue, pleural effusions
* Liver -> decreased iron due to decreased absorption
- Felty Syndrome
what components and what does it lead to
RSL
* Rheumatoid arthritis
* Splenomegaly
* Leukopenia
this leads to life-threatening infections
Rheumatoid Arthritis
Physical Exam
and labs
PE:
* Typical RA pattern is a chronic, symmetric polyarthritis with a tendency to affect the small joints of the hands and feet.
* Ulnar deviation of hand
* Swan neck & Boutonniere deformities
* Rheumatoid nodules over bony prominences
* C1-C2 subluxation; cervical spine involvement
* MORNING STIFFNESS
Labs
* Positive Rheumatoid factor in 60-80%
* Anti-cyclic citrullinated peptide antibodies (Anti-CCP) most specific. (SEROPOSITIVE)
* +ANA
* Increased ESR & CRP
* Anemia
* Synovial fluid analysis
Rheumatoid Arthritis
Treatment
- Methotrexate & Leflunomide preferred initial treatment.***
- Disease Modifying Anti-Rheumatic Drugs (DMARDs)- DMARDs work to suppress the body’s overactive immune and/or inflammatory systems. Prompt initiation to slow disease progression.**
- Take weeks to months for effect
- Traditional DMARDs- Methotrexate, Leflunomide, Hydroxychloroquine, Sulfasalazine.
- NSAIDs & Glucocorticosteroids for symptom relief, not to modify disease progression.
- Occupational & Physical therapy
Rheumatoid Arthritis
Diagnosis
Radiographs
* Symmetric joint space narrowing
* Osteopenia
* Bone & Joint erosions
* Joint subluxation
There is no single physical exam finding or lab test that is diagnostic for RA
* Morning Stiffness is hallmark of symptoms*
* Symmetrical joint involvement
* Swan neck & boutonniere deformities in hands
* Cervical spine involvement, especially C1-C2 Subluxation
* Felty syndrome - RA, splenomegaly, leukopenia***
* Synovitis is common
* Sjogren syndrome associated with RA (decreased salivary & lacrimal gland secretion, dry eyes and mouth)
Juvenile Idiopathic Arthritis
overview and dx and subtypes
- Chronic inflammatory arthritis in a child < 16y.o. with symptoms >6 weeks.
- Joints warm & painful.
- Stiffness lasting > 30 in morning or period of inactivity.
- One of the most common childhood diseases comparable to diabetes.
- Classification based on number of joints, RF +/- and HLA B27 positivity.
- Clinical diagnosis.
- 3 Main subtypes: OLIGOARTICULAR MC*
- Important to diagnose and treat early to limit damage, preserve functionality, & avoid chronic pain.
DX IS PRIMARILY CLINICAL*
Systemic (Still’s Disease >16 y.o) overview and labs
Juvenile Idiopathic Arthritis
- Name implies systemic features along with arthritis.
- Arthritis in one or more joints with fever of at least 2 weeks.
- Peak age = 2 y.o. Accounts for 10-15% of children with JIA
- Daily or diurnal fever.**
- Salmon-colored pink migratory rash on trunk & extremities.**
- Generalized lymphadenopathy, hepatomegaly &/or splenomegaly or serositis
Labs:
* CBC
* Anemia, leukocytosis, thrombocytosis
* Elevated CRP, ESR, Serum ferritin
* Negative RF, anti-CCP,ANA*****
Oligoarticular or Pauciarticular overview and labs
Juvenile Idiopathic Arthritis
- Affecting 4 or fewer joints during the first 4 months of disease.
- Medium to large joints most common.
- Temporomandibular joint often affected.
- Positive ANA: increase risk of asymptomatic uveitis
- Peak age 1-3 y.o.
- Accounts for 30-80% of all JIA diagnoses.*** M.C. in females of European descent.
Labs
- Negative RF, anti-CCP
- +/- ANA
Polyarticular overview and labs
Juvenile Idiopathic Arthritis
- Chronic inflammatory arthritis in 5 or more small joints during the first 6 months of disease.
- Ages 2-5 years old or 10-14 years old
- Similar to adult RA
- Uveitis is common if RF negative***
- Accounts for approx 20% of JIA cases. 85% of them are RF negative.
- Worse prognosis if RF positive.
Labs: not super helpful; primary a clinical dx
* CBC - anemia
* Elevated ESR
* +/- RF, anti-CCP, ANA
Juvenile Idiopathic Arthritis
Diagnosis
Primarily Clinical
ESR & CRP positive
Oligoarticular = +ANA, RF neg & Anti-CCP neg
Polyarticular = RF negative (m.c.)
Systemic = RF neg & ANA neg
Juvenile Idiopathic Arthritis
Treatment and prognosis
tx:
* Based on sub-type
* Historically NSAIDs are first line.
* Biologics TNF- inhibitors, Il-1, Il-6 inhibitors.
* Conventional DMARDs are shifting to first line, particularly in polyarticular. Methotrexate
* Glucocorticosteroids injections if fewer than 4 joints are affected.
* Juvenile Idiopathic Arthritis
Prognosis:
* Disease prognosis varies on sub-type.
* 50% of patients with persistent oligoarthritis go into remission.
* RF positive polyarthritis associated with lowest rates of remission & worst outcomes. Often require lifelong medication maintenance.
