Rheumatoid disease

Question 1

What is a rheumatoid disease?

Answer 1

It is a systemic autoimmune disease characterized by inflammatory polyarthritis, which affects peripheral joints, especially the ones of the hand and the feet

• Autoimmune due to the failure of tolerance
• It has a remission and can relapse if not well managed it can lead to a disability

Question 2

Describe the epidemiology of rheumatoid arthritis

Answer 2

• It has a prevalence of 1%
• More common in women (3:1) due to the increased amount of stressors
• Peaks at the fourth or fifth decade for a woman and the sixth to eighth decade of a man
• 40% are registered as disabled within 3 years of onset while 80% are moderately-severely disabled within 20 years

Question 3

What is the cause behind rhematoid arthritis?

Answer 3

1) Genetic factors

2) Environment

3) Immune system

4) Familial association

5) There is a link between MHC class II gene, HLA-DR4 & HLA-DR1

-The main cause is unknown but it is an interplay between different factors and genetics like MHC

Question 4

Describe the pathophysiology of rheumatoid arthritis

Answer 4

1) Onset:
- Infiltration of the synovial membrane with (lymphocytes, plasma cells, dendritic cells, & macrophages)

• macrophages will present antigens to the CD4 cells that activates B-cells releasing antibodies to attack

2) Formation of lymphoid follicles where T & B-cells interact leading to the production of cytokines and autoantibodies (including Rhematoid factor)

• the Rhematoid factor is what we test in the lab for the diagnosis

3) Activated by the immune system, synovial macrophages produces proinflammatory cytokines including (TNF, IL-1, IL-6 & IL-15), this will recruit more macrophages, inflammatory cells, osteoclasts and chrndrocytes

• Proinflammatory cytokines will act on the synovial fibroblasts to promote swelling of the synovial membrane and damage to the soft tissues and cartilage
• Activation of the osteoclasts and chondrocytes will drive the destruction of the bone and cartilage
• Neo-angiogenesis (formation of new BV) will start as the RA joint gets hypoxic

4) Formation of a pannus: granulation tissue that formed above and under the articular cartilage that is progressively erroded and destroyed leading to fibrous or bony ankylosis and the atrophy of adjacent muscles that might be infiltrated with lymphocytes

Question 5

What causes bone erosion in Rheumatoid arthritis?

Answer 5

1) Release of collagenase and protease by neutrophils (destruct the extracellular matrix)

2) Release of cytokines from the macrophages which will activate chondrocytes and osteoclasts

Question 6

What happens if rheumatoid arthritis is left untreated?

Answer 6

Osteoporosis

Question 7

What is meant by fibrous ankylosis?

Answer 7

fixation on the joint to excess fibrous tissue (the joint is glued and fixed) if it gets ossified it will turn into a bony ankylosis

Question 8

What is the difference between a healthy and a rheumatoid joint?

Answer 8

1) Healthy:
- Synovium is normal
- Very thin layer of synoviocytes
- Uniform

2) Rheumatoid:
- Piling of synoviocytes due to hyperplasia
- Bluish coloration (pannus)
- Accumulation of inflammatory cells
- Neo-angiogenesis formation

Question 9

How can you distinguish a rheumatoid microscopic slide?

Answer 9

• Finger-like protrusion
• Dark aggregates of epithelial cells

Question 10

What are the clinical findings (signs and symptoms) of rheumatoid arthritis?

Answer 10

• It is highly variable

1) Symmetric swelling of multiple joints with tenderness and pain

2) >6 weeks of pain, swelling, and warmth of the joint, with symmetric joint involvement (hand, wrist, or feet)

3) >1hr of morning stiffness

4) The joint is commonly sore, stiff, and painful after sleep or after resting for a while (which loosens after you get up)

5) Hand deformities (swan eck & boutonniere)

6) Ulnar deviation

7) Synovial swelling at the wrist, extensor tendon sheaths, the metacarpophalangeal and proximal interphalangeal joints

8) In late stages we can also see MCP subluxation and Z-shaped thumb

Question 11

What are the most common joints involved in rheumatoid arthritis?

Answer 11

1) Metacarpal phalangeal joint

2) Proximal inter-phalangeal joints

3) Distal inter-phalangeal joints

4) Wrist

5) Ankle

6) Shoulders

7) Hips

8) Knees

9) MTP (Metatarsal - proximal phalanges) in the foot

Question 12

Describe the swan neck deformity

Answer 12

It is a hyperextension of the proximal interphalangeal joint (PIP) and flexion of the distal interphalangeal (DIP) joint

Question 13

Describe the boutonniere deformity

Answer 13

1) PIP flexion

2) DIP hyperextension

• Tears is visible on the PIP joint skin

Question 14

What are some of the extra-articular manifestations involved in rheumatoid arthritis?

Answer 14

1) Systemic

2) Musculoskeletal (Muscle-wasting, Tenosynovitis, Bursitis, Osteoporosis)

3) Hematological (Anemia, thrombocytosis, eosinophilia)

4) Lymphatic

5) Nodules

6) Ocular

7) Vasculitis

8) Cardiac

9) Pulmonary (Nodules, Pleural effusions, Fibrosing alveolitis, Bronchiolitis)

10) Neurological

Question 15

Describe anemia in rheumatoid arthritis

Answer 15

1) Anemia of chronic diseases: It is still not completely understood but is thought to be due to the reduction in RBC production by the bone marrow

2) Iron deficiency anemia: Caused by the chronic blood loss from gastritis which is a side effect of NSAID drugs taken by rheumatoid arthritic patients

3) Bone marrow hypoplasia: A serious complication of RA, associated with Felty’s syndrome, renal failure and the administration of immunosuppressive agents

Question 16

What is the most common skin manifestation in rheumatoid arthritis?

Answer 16

• Cytokines profile and they can produce metalloproteinases establishing a nodule as a Th1 granuloma (Granuloma is a chronic specific inflammation, in which the main cells are epithelioid cells which are activated macrophages)
• Rheumatoid nodules (behind the elbow “olecranon process”, in pressure points)
• They tend to occur in the extensor surface adjacent to joints, elbows, and fingers as well as the forearm, metacarpophalangeal, and PIP joints and other areas
• The nodules are painless, but they can be painful, disfiguring, and interfere with the function, and cause compressive neuropathies, they might also ulcerate serving as a site for local inflammation

Question 17

What is one of the complications of methotrexate therapy in some patients?

Answer 17

Increased formation of Rheumatoid nodules

Question 18

How can you diagnose RA?

Answer 18

1) Clinical criteria

2) ESR & CRP (elevated in RA, as they are markers of inflammation)

3) Ultrasound/MRI

4) Rheumatoid factor

Question 19

How can we monitor the damage caused by RA?

Answer 19

1) X-rays

2) Functional assessment

Question 20

How can we monitor the drug safety of RA?

Answer 20

1) Urinalysis

2) Full blood count

3) Urea, creatine, and liver function tests