Lecture 94 - RA (+ Sjogren's)

Question 1

what is RA

who is commonly affected

Answer 1

chronic d/o of systemic inflammation affecting the synovial membrane . Most common form of inflammatory arthritis

Women > Men

Question 2

what are the 3 factors of pathogenesis

Answer 2

Genetic susceptibility – HLADR4

Trigger – EBV, Retrovirus, Parvo B19, Porphyromonos gingivalis (oral flora which coverts arginine to Citruilline)

Environemntal factors – Cigarette smoking (upregulates PAD enzymes which convert arg–> Citruilline)

Question 3

what is the associated HLA phenotype

possible infectious triggers

environemntal risk facrtor

Answer 3

Genetic susceptibility – HLADR4

Trigger – EBV, Retrovirus, Parvo B19, Porphyromonos gingivalis (oral flora which coverts arginine to Citruilline)

Environemntal factors – Cigarette smoking (upregulates PAD enzymes which convert arg–> Citruilline)

Question 4

what auto antibodies are found in RA – what are they ?

Answer 4

RF – IgM antibody against FC portion of IgG

ACPAs –Anti–citrullinated protein antibody

Question 5

what is pannus ? what deformities can it lead to in RA?

Answer 5

Pannus = Granulation Tissue – blood vessels, fibroblats and myofibroblasts

Ulnar Drift – digits drift to the ulnar side; IO muscle wasting; Pannus over the MCPs

Non Reducible Swan Neck (Hyperflexion of the DIP, Hyperextend the PIP, Flex MCP)

Question 6

Constituional features of RA

Answer 6

fever, weight loss, fatigue, lethargy

Question 7

articular features of RA – what joints are commonly affected

what jounts are never or rarely involved

Answer 7

Additive and Symmetric Arthritis – affecting the small joints of the hands

		Commonly: PIP, MCP, MTP, C1, C2 

Lower back and DIP

Question 8

patterns of stiffness and pain throughout the day

Answer 8

morning stiffness > 1 hour

Pain improves throughout the day

Question 9

common extra-articular featurs of RA

Answer 9

Rheumatoid Nodules

Ocular involvement – episcleritis

Sjogren’s syndrome

Carpal Tunnel

Pericaditis

LAD

Vasculitis

Felty’s Syndrome

Osteoporsis

Amyloidosis

Question 10

what is sjogren’s syndrome

classic clinical appearance

Answer 10

Autoimmune targetting of the Exocrine Glands –

		Symptoms: dry eyes + Dry mouth, parotitis 
			Predisposition to Caries, Cavities and Tooth Loss

Question 11

what is the triad of symptoms in felty’s syndroe

Answer 11

Triad: Splenomegaly, leukopenia, Rheumatoid Arthritis

Question 12

histology of rheumatoid nodules

where do they commonly appear

Answer 12

Pallisading features of rhematoid nodules

Where: extensor surfaces of forearm or other pressure sites + Lung

Question 13

heamtologic findings of RA?

serologic findings of RA? which is more sensitive/specific

Answer 13

Anemia of chronic disease
ESR and other markers of inflammatin

RF  -- titers correlate with severity 
Anti CCP (ACPA) -- more sensitive and specific

Question 14

XR findings in RA

Answer 14

Oestopenia

Marginal Erosions in Bone  -- "bites" out of the margin of the bone 

Joint Space Narrowing -- least specific (could easily be OA)

Question 15

causes of moratlity in RA patients

Answer 15

lung disease, vasculitis, lymphoma, infection via use of biologics
CV risk

Question 16

treatment options of

Answer 16

NSAIDs
Oral Prednisone –

			MTX – folate antagonists; watch for hepatotoxicity 
			Cyclosporine, 
			\azathioprine 

Remicaide – infliximab – IV infusions; anti TNF 
Adalimumab (humira) – anti TNF
Rituximab - -Anti cD20 
Anakinra – anti-IL1 
Abadacept – CTLA4