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Rheumatoid Arthritis

Rheumatology

QuestionAnswer
Joints most affected by RA ankles, wrists, shoulders
RA epidemiology Worldwide: 0.8% adult; US: F 40-50/100,000; M 20-25/100,000; by age 65 M:F = 1:1; Lifelong; 3-5 yr reduction in life exp; Incidence is declining
RA pathogenesis Genetics: both susceptibility & dz severity; HLA-DR 1 and DR4 alleles
RA: Poss infectious triggers: Mycoplasma, Mycobacterium, enteric bacteria; rubella, parvovirus B19, EBV
RA: Other poss risks: tea, high vitamin D intake, silicate exposure
RA pathology trigger; prolif syn macrophages / fibroblasts; lympho invade perivascular space; affected jt vessels occluded, synovium forms pannus (which invades cart & bone); cytokines, proteinases, ILs released; jt destn
RA Clinical manifestations: slow, insidious onset; durations of sx = wks to mos; fatigue, malaise, low-grade fever, wt loss; 10-15% advanced, fulminant sx; joints are typically swollen (boggy) and/or warm; erythema not common
RA: pts c/o pain & stiffness: 2/3 pts c/o pain & stiffness in multiple joints, 1/3 c/o pain and stiffness in one or a few joints
RA classic presentation: small bones of hands/feet most likely to be affected early (PIPs, MCPs, MTPs)
RA: progression to larger joints: wrists, knees, elbows, ankles, hips, shoulders
RA: around inflamed joints: may be atrophy of muscle around inflamed joints
RA typical course: waxing/waning over years with acute episodes involving single or multiple joints
RA: Articular manifestations: hands ulnar devn; swan neck deform (PIP hyperext), boutonniere (PIP hyperflex & DIP hyperext)
RA: Articular manifestations: feet affected in 90% of pts w/ longstanding RA; subluxation of MTP joints leads to callus formation
RA: Articular manifestations: wrists in most pts; radial deviation; inc synovial proliferation leads to median n. compression, tendon rupture
RA: Articular manifestations: other joints: any synovial joint can be affected; TMJ, cricoarytenoid, sternoclavicular joints
RA: Articular manifestations: c-spine: C1-C2 articulation; atlantoaxial subluxation is feared complication (d/t ligamentous laxity induced by synovial prolif)
RA atlantoaxial subluxation presenting sxs: pain radiating up occiput; slowly prog quadriparesis w/ inc sensation in hands; UE paresis triggered by head movements; transient episodes of vert art compression
RA: joints most commonly affected MCP, PIP, wrists, knees, shoulders
RA: Labs no single dx test confirms RA; acute phase reactants (ESR, CRP, thrombocytosis); autoAbs (RF, anti-CCP, ANA); anemia of chronic dz; synovial fluid analysis; inc WBCs, mostly PMNs
RF testing RF result changes over time (some: seroneg RA) (so if neg, sd test periodically later)
Lab results: Ro, La, Smith, & RNP: don’t change over time
RA labs: CCP more specific for RA than RF; 30% RA pts are RF neg; 60% RA pts CCP pos; CCP pos at risk for severe dz
RA Imaging: must ID changes early (avoid irreversible joint damage); sig amt genl skeletal bone lost early in dz
RA: prevalence of osteoporosis = 2x that of general population
RA Imaging: early findings: soft tissue swelling, peri-articular osteopenia, marginal erosions
RA Imaging: late findings: diffuse osteopenia, joint space narrowing, deformities
RA Tx: mod-severe dz at dx: start with DMARDs (combo tx); titrate dose upward as needed; add biologic tx for uncontrolled joint pain, swelling
RA Tx: mild dz: less aggressive DMARDs (hydroxychloroquine, sulfasalazine)
RA Tx: adjuncts: glucocorticoids, NSAIDS, analgesics, PT / occupational tx
RA complications: Inc risk of CV disease: premature, accelerated atherosclerosis 2nd to chronic inflame; Inc rate of malig (usu lymphoma); atlantoaxial subluxation
Felty’s syndrome: rare: RA & splenomegaly, leukopenia & recurrent pulmonary infxn; poss also leg ulcers, vasculitis
Baker’s cyst: rupture of synovial fluid from knee into calf; mimics DVT, cellulitis
RA: Predictors of poor prognosis: low functional score, low SES, inc ESR, CRP, early radiographic changes
RA: Plain films show joint damage after: 2 years of dz duration in 70% of cases
RA: MRI scans reveal: erosive joint damage as early as 4 months
RA: Primary care mgmt: disability; med AE (edema); surveil for infxn, malig, osteoporosis, depression; immunizations; CV risk reduction
Joints most affected by RA ankles, wrists, shoulders
RA pathogenesis Genetics: both susceptibility & dz severity; HLA-DR 1 and DR4 alleles
RA: Poss infectious triggers: Mycoplasma, Mycobacterium, enteric bacteria; rubella, parvovirus B19, EBV
RA Clinical manifestations: slow, insidious onset; sxs wks to mos; fatigue, malaise, low-grade fever, wt loss; joints typically swollen (boggy) and/or warm; erythema uncommon
RA classic presentation: small bones of hands/feet, usu affected early (PIPs, MCPs, MTPs); progression to larger joints (wrists, knees, elbows, ankles, hips, shoulders)
Created by: Abarnard