questions 7

Rheumatoid Arthritis

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Topic updated on 01/30/17 1:40am

Snapshot
  • A 32-year-old female presents with complaints of joint stiffness over the last two months. She claims it is worse in the morning. On physical examination, her wrists and MCP joints are red and erythematous. In addition her right knee is red and erythematous.
Introduction
  • Definition
    • chronic, destructive, autoimmune systemic inflammatory arthritis of unknown etiology
      • may have infectious inciting agents
      • pannus formation and subsequent cartilage erosion
    • characterized by symmetric involvement of both large and small joints
  • Epidemiology
    • most common in females 20-40 years old
    • high incidence with people that have HLA-DR4 serotype
  • Pathophysiology
    • immunology 
      • cell-mediated (T cell MHC type II) immune response against soft tissues (early), cartilage (later), and bone (later)
        • rheumatoid factor
          • an IgM antibody which recognizes and attacks native IgG antibodies
          • type III hypersensitivity: immune complex is then deposited in end tissues like the kidney as part of the pathophysiology
        • mononuclear cells
          • are the primary cellular mediator of tissue destruction in RA
        • IL-1 and TNF-alpha
          • are part of cascade that leads to joint damage
        • immune response thought be related to
          • infectious etiology or
          • HLA locus
    • pathoanatomy
      • cascade of events includes
        • antigen-antibody and antibody-antibody reactions 
        • microvascular proliferation and obstruction 
        • synovial hypertrophy/pannus formation 
          • results in erosion of adjacent cartilage, bone, and tendons
        • joint subluxation, chondrocyte death/joint destruction, and deformity 
        • tendon tenosynovitis and rupture
Presentation
  • Symptoms
    • symmetric arthritis worse in morning
    • pain/stiffness improves with use
    • usually affects hands and feet
      • DIP joint of hand is usually spared
      • may also affect knees, cervical spine, elbows, ankle, and shoulder
    • extra-articular joint manifestations include
      • subcutaneous nodules 
        • known as rheumatoid nodules
        • correlate with high RF titers
        • fibrinoid necrosis
      • restrictive lung disease
        • chronic pleuritis with interstitial fibrosis
        • called Caplan syndrome
      • carpal tunnel syndrome
      • cardiac inflammation
        • fibrinous pericarditis
  • Physical exam
    • ulnar deviation of the MCPs
Evaluation
  • Serology
    • elevated RF (most commonly IgM)
      • targets the Fc portion of IgG 
      • elevated in 75-80% of patients with RA
      • not specific for RA
    • elevated ESR ( > 90% )
      • not specific for RA 
    • anti-CCP 
      • highly specific for RA
    • possible neutropenia
      • autoimmune destruction of neutrophils
      • if associated with splenomegaly it's known as Felty's syndrome
  • Diagnostic criteria
    • morning stiffness and swelling
    • subcutaneous nodules
    • positive laboratory tests
    • radiographic findings
 
Treatment
  • Medical
    • NSAIDS or COX 2 inhibitors are first line
    • DMARDs
      • methotrexate 
      • cyclosporine
      • hydroxychloroquine
        • patient must be annually checked due to adverse side effect of retinopathy
      • gold
    • TNF-alpha inhibitors
  • Physical therapy/occupational therapy
    • important to prevent ankylosis of involved joints


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Qbank (2 Questions)

TAG
(M1.MK.15) A 38-year-old female visits your office complaining of several years of joint swelling and stiffness that is worse in the morning and improves throughout the day. Physical examination reveals bilateral deformities at her proximal interphalangeal and metacarpophalangeal joints. The presence of which of the following in this patient’s serum would most help 'rule in' a diagnosis of rheumatoid arthritis: Topic Review Topic

1. Rheumatoid factor
2. Anti-nuclear antibody
3. Anti-citrullinated protein antibody
4. Anti-centromere antibody
5. Anti-smooth muscle antibody

PREFERRED RESPONSE ▶
TAG
(M1.MK.4666) A 35-year-old woman presents with a 4-month history of hand pain that is worse when awakening in the morning. She reports that her pain improves throughout the morning. Both hands are equally affected. Findings from a physical examination are shown in Figure A. Which of the following autoantibodies is highly specific for this patient's disorder? Topic Review Topic
FIGURES: A          

1. Anti-Smith antibodies
2. Antihistone antibodies
3. Anticentromere antibodies
4. Anti-IgG antibodies
5. Anti-citrullinated protein antibodies

PREFERRED RESPONSE ▶
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