Rheumatoid arthiritis

rheumatoid arthritis
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Terms in this set (23)
rheumatoid arthritis
a chronic (> 6 weeks)autoimmune inflammation disease
-symmetrical, progressive and erosive-destructive joint injury, causing functional disability, and multiple extraarticular manifestations.
-Onset is commonly associated with infectious trigger; emotional or physical stres
Epidemiology
More in female (2-3 X)
- 35-50 years
- Caucasians
Risk factors
Female, Early menopause
-low level testoterone (men)
-Smoking, coffee
-Obesity
- Diet(red meat)
-infectious (ebv, Parvovirus 19)
-Medications (statin)
-Genetics HLA-DR4
Serology (antibodies)
1. -Rf -Rheumatoid factor (RF) - positive 60-70% patients, diagnostic and prognostic marker
2. -Anti CCP antibody (ACPA)
high specificity
may precede disease onset by about 10 years - major importance in early diagnosis
3. -ANA (IgM)-in 30% of cases
arthritis
- Inflammatory, symmetrical
- affects joints with highest ratio between synovial surface and articular cartilage
- Most afected joints - diartroidal joints: PIP, MCP, MTP
- first affected joints are: MCP II-III, MTP V.
- dose not afect - distal interphalangeal joints (DIP) - characteristic in RA
Hand Joints
Wrist, Metacarpals, MCP, PIP, Not DIP.
Swan neck, Butoniere, PIP swelling, Radial deviations, Carpal tunnel syndrome.
- interosseuous muscles atrophies
Other joints
-swollen knee + hydrarthrosis
-elbow fixed in semiflexion, with extension limitation and pronation;
-Shoulder fixed in adduction and internal rotation
Foot
--halus valgus + external deviation(1)
-fingers "in claw" or in "hammer"
-flat foot (flattening arch of plantar arch)
cervical vertebrae
- only axial segment affected in RA
-atlanto-axial subluxation with anterior axis movement is clinically manifested - irradiated cervicalgia in occiput and may progress to spastic paraparesis
- advanced stages, signs of bone marrow compression appear:
Sensation of head loss in front of the flexion of the spine
Syncope, disorders of consciousness
Affect sphincter control
Dysphagia, dysarthria, nystagmus
Radiography - distance> 3 cm between odontoid process and axial
arch 2)
Rheumatoid nodules
Firm, nontender, unattached subcutaneous nodules at pressure points (e.g., elbow, back of forearm) associated with rheumatoid arthritis
-can also be located at level of: sclera, larynx, heart, lungs, pleura, kidney
Extraarticular manifestations of RA
Eye disease*** - keratoconjuctivitis sicca, uveitis, scleritis, episcerlitis
Sjogrens syndrome (dry eyes and dry mouth)

Felty's syndrome
Vasculitis
Pulmonary (pleuritis, ILD, pulmonary nodules)
Cardiac (pericarditis, Interstitial cardiomyopathy)
Radiography signsEarly signs: increased epiphyseal transparency ("band-like osteoporosis") is earliest sign, appearing initially in the MCP, MTP, PIP, but can also occur in other diseases - epiphyseal bone erosion + geode; - joint space narrowing Late signs: - Loss of joint space - crenellated aspect of bone edges - deformities and subluxations, up to fusion or joint ankylosis MRI is gold standard1987 classificationRheumatoid Arthritis (1987 Revised Classification Criteria) 1. Morning stiffness (in/around joints, at least 1 hour before maximal improvement) 2. Arthritis (swelling) of 3 or more joint areas (observed by physician) 3. Symmetric arthritis (swelling, NOT bony overgrowth) Arthritis of Hand joints (wrists, MCPs or PIPs) 4. Rheumatoid nodules 5. Rheumatoid factor (serum) 6. Radiographic changes (erosions and/or peri-articular osteopenia in hand/wrist joints) Requirements: ≥4 of the above 7 criteria . *Criteria 1-4 must have been present for at least 6 weeksEular 2010A. Joint involvement 1 large joint 0 points 2-10 large joints 1 points 1-3 small joints (with/ without involvement of large joints) 2 points 4-10 small joints (with/ without involvement of large joints) 3 points >10 joints (at least 1 small joint) 5 points B. Serology - Low-positive RF or ACPA 2 points High-positive RF or ACPA 3 points C. Acute-phase reactants either CRP or ESR (or both) 1 point D. Duration of symptoms ≥ 6 weeks 1 point -6/10 for positive diagnosis.Steinbrocker ClassificationStage I (Early) without destructive radiological lesions, - osteoporosis STAGE II (Moderate) Osteoporosis - slight destructive lesions of bone/ cartilage, - nearby atrophy Stage III (severe advanced) -Osteoporosis - destructive bone / cartilage lesions - extensive muscle atrophy, - subcutaneous nodules - deformities: subluxation, ulnar deviation, hyperextension, without ankylosis; STAGE IV (terminal) Stage III + signs of bony ankylosisFunctional Diagnosis Criteria by Steinbrocker.Stage or grade I No limitation of activity Stage or grade II - normal activity with or without pain, - limitation of movement Stage or grade III - Functional impotence is important, but patient still has retained autonomy; Stage or grade IV Functional impotence is total or subtotal - patient needs attendant - dependent socially - disability (bedridden or chair)DAS 28 scores- is used to assess disease activity and treatment response including both biological and clinical parameters, examining a total of 28 articulations. - Swollen and Tender joints Plus ESR or CRP - remission: ≤ 2.6 - low disease activity: >2.6 - ≤ 3.2 - moderate disease activity: > 3.2 - <5.1 - high disease activity: ≥5.1SDAI and CDAIS= spimplified C= clinical - nr of swollen , tender joints, Patients own assesment (0-10). - SDAI is used when CRP is available - CDAI Is used when no CRPSDAIDD1. Rheumatic fever (Asymmetrical, migratory, not progressive pattern Large joints of lower limb ) 2. Lupus (is not deforming or destructive, serology differents) 3. Seronegative spondyloarthiritis (young Male, HLA-B27, Assymetrical, No serology, Spine involvement ) Others: Gouts, Sarcoidoisis (Skin and nail menifestation, No ACPA, DIP is involved)Symptomatic medication:NSAIDs local corticosteroid general corticosteroidsDMARDsdisease-modifying antirheumatic drugs -1.Synthetic (or chemical) = sDMARDs; 2. Biological = bDMARDS - remissive terapy - Methotrexate (Gold Standard) - Leflunomid - Hydrochloroquine - sulfasalazine - D-Penicillamine - Cyclophosphamide - Azathioprine Cyclosporinebiological therapy- Anti-cytokine agents: Anti-TNFα; (etanercept, infliximab Adalimumab Golimumab Certolizumab) - Anti-IL-1(Anakinra) - Anti-IL-6 (Tocilizumab) - Anti- B cells (Rituximab) - Antagonists of co-stimulatory molecules (Abatacept)Non-pharmacologic therapy- Topical treatment - orthopedic - Physiotherapy -Hygienic and dietary treatment -psychotherapy