Rheumatology: Inflammatory Arthritis Flashcards
(34 cards)
Rheumatoid arhthritis - examination findings [4]
- Soft-tissue swelling over the joints with tenderness.
- Joint deformities: swan-neck and boutonniere in the fingers, Z-thumb, ulnar deviation at the MCP
joints, radial deviation of the wrist joint, over-riding and hammer toes. - Rheumatoid nodules (~20% of patients):
◆ Firm, mobile and usually over pressure points.
◆ Consist of fibrinoid necrosis and palisading histiocytes. - Muscle weakness (due to disuse atrophy), tenosynovitis and bursitis.
Rheumatoid arthritis Investigations
- Synovial fluid analysis
Bloods - FBC: normochromic, normocytic or hypochromic microcytic anaemia, thrombocytosis, neutropenia associated with Felty’s syndrome
- Inflammatory markers (ESR and CRP): elevated, especially in acute flares.
- Auto-antibodies (RF and anti-CCP): anti-CCP has greater sensitivity and specificity than RF. Anti-
CCP can be detected several years prior to onset of RA - Renal, liver and bone biochemistry: to exclude other pathologies and prior to institution of medical
treatments.
Radiology
- Plain film radiography.
- Joint US examination.
- MRI of small joints of the hands and feet may help (e.g. peri-articular osteopaenia, erosions, joint
space narrowing), where plain films and US have been unremarkable.
Rheumatoid arhtritis extra-articular manifestations
skin, bone, haema, resp, cardio, ocular, renal, neuro
Rheumatoid arhtritis
Poor prognostic indicators [4]
- Presentation- insiduous onset, constitutional sx, poor functional state at 1y, social deprivation, high disease activity score on presentation.
- Demographic- female, smoking
- Biochemical - high inflammatory markers, shared epitope HLA-DRB*04 cluster. RF positivity with high titres (especially IgA RF) and anti-CCP.
- Radiological- early erosions
Synovial fluid in RA
- Inflammatory diseases may show yellow or green with decreased viscosity
- High WCC - neutrophilia, lymphocytosis
- Glucose may be low in RA as it is in bacterial infections.
RA Definition
Chronic autoimmune systemic illness
characterised by symmetrical peripheral arthritis
and other systemic features
RA diagnosis needs a score of x according to 2010 EULAR Classification
6 OR MORE out of 10
4 sub-categories of RA Classification/Criteria
In each sub-category, what would score high pointing to a dx of RA?
Joint Involvement (poly + small joints)
Serology (RF +ve, ACPA +ve)
Acute phase reactants (raised)
Duration of symptoms 6w
Epidemiology of RA
Gender
Prevalence
Peak age of onset
But may occur at any age from ____
F:M 3:1
1% of population
4th or 5th decade
But may occur at any age from 16 y
Aetiology RA
Genetic - closest association with specific amino acid sequences at positions ____ of _____
What are the susceptibility genes?
Environmental factors (2)
Genetic - closest association with specific amino acid sequences at positions 70-74 of DRb1
HLA DR1 and HLA DR4
Environmental factors:
Smoking
Chronic infection - peri-odontal disease
Pathogenesis RA
3 stages
Rheumatoid factor binding to IgG forming immune complexes
Not easily cleared
Activate complement - further inflammation
Activation of macrophages
RA Symptoms 4
Pain
Swelling
Loss of function
Systemic symptoms
Symptoms RA
- Systemic symptoms
- Non-specific (3)
Fatigue
Weight loss
Anemia
Which types of malignancy have higher incidence assoc with RA
Leukemia and Lymphoma
DAS28 score - how does it relate to RA?
What score represents clinical remission?
What score indicates eligibility for biology therapy
DAS28 score – monitor disease activity (disease activity score)
DAS<2.4 represents clinical remission
DAS>5.1 represents eligibility for biologic therapy
4 modes of management of RA
NSAIDS
DMARDS
Biologics
Corticosteroids
Name 4 DMARDs used in RA
Whats the gold standard DMARD drug
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Name 5 drugs under ‘Biologics’ category of RA MX
TNF-alpha inhibitors Etanercept
IL-1 inhibitors Anakinra
IL-6 inibitors Tocilizumab
Anti-B cell therapy - Rituximab
Anti-T cell therapies - Abatacept
What are the extra-articular manifestations of RA? [4]
Extra-articular
- Rheumatoid nodules
- Increased risk of atherosclerosis
- Interstitial lung fibrosis
- Pleural effusions (SOB)
What is Felty’s syndrome? Why can it be dangerous?
Triad of:
RA
Splenomegaly
Granulocytopenia
Can lead to life-threatening infections
X-ray of RA
Early [3]
Late [3]
soft tissue swelling, juxta-articular osteopenia, loss of joint space
Late changes: bony erosions, subluxation, complete carpal destruction
L – loss of joint space
E – erosions
S – soft tissue swelling
S – soft bones (osteopenia)
What finding would you see on FBC
Increased platelets
DMARDs
Indications for prescribing [1]
How long before patient should expect symptomatic benefit [1]
Best results with? [3]
SE [3]
How to counter this side effect [1]
Should be started within 3 months of persistent symptoms
Can take 6-12w for symptomatic benefit
DMARD monotherapy +/- a short-course of bridging prednisolone (NICE, 2018)
SE: immunosupression, pancytopenia, neutropenic sepsis so regular FBC monitoring
DMARDs side effects
Methotrexate [3]
Sulfasalazine [3]
Leflunomide [4]
Hydroxychloroquine [1]
Methotrexate - pneumonitis, oral ulcers, hepatotoxicity
Sulfasalazine - rash, decreased sperm count, oral ulcers
Leflunomide - teratogenicity, oral ulcers, increased BP, hepatotoxicity
Hydroxychloroquine - Bull’s eye retinopathy
