Rheumatology

• Biologic response modifiers, such as tumor necrosis factor (TNF) inhibitors, can target specific molecules involved in the immune response and reduce inflammation in rheumatoid arthritis.
• Other types of arthritis include gouty arthritis, septic arthritis, reactive arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE), scleroderma, dermatomyositis, polymyalgia rheumatica, fibromyalgia syndrome, and vasculitis.
• Rheumatoid arthritis is an autoimmune disease where the body's immune system attacks healthy joint tissues, causing inflammation and damage.
• #tags column:3
• Polyarticular symmetric involvement is characteristically seen with? RA, SLE, parvovirus B19, and HBV
• Monoarticular arthritis seen in? 1. Gout2. Pseudogout 3. Trauma 4. Hemarthrosis5. Osteoarthritis 6. Septic arthritis 7. Palindromic RA 8. Reactive arthritis
• Migratory arthropathy (inflammation and pain migrate from joint to joint while the previous involved joints improve) is caused by? 1. Lyme disease2. Rheumatic fever3. Disseminated gonococcal ­infection
• Oligoarticular asymmetric arthritis is common with? 1. Spondyloarthropathies (ankylosing spondylitis) 2. OA involving the small joint of the upper extremities3. Rarely in the presentation of polyarticular gout
• Monoarticular arthritis for months to years»» OAMonoarticular arthritis for only a few days»» septic arthritis or crystal-induced arthropathy
• OA presents with an absence of systemic symptoms
• What are the basic tests to run on the ­aspirated synovial fluid? - 3 Cs (cell count, crystals, and cultures) - Gram stain
• What are the CIs of joint aspiration? - Cellulitis- Bleeding diathesis
• What do WBC count point to in synovial fluid analysis in rheumatologic disease? "Septic arthritis + negative synovial Gram stain and culture suggests gonococcal arthritis "
• Anti-RNP is found in 100% mixed connective tissue disease (MCTD)
• While RF antibodies are neither sensitive nor specific for the diagnosis of RA, how can they be important? Their presence can be of prognostic significance: patients with high titers tend to have more aggressive disease with extraarticular manifestations.
• What are the rheumatoid factors (RFs)? IgM autoantibodies against the Fc portion of IgG
• Where can we find C-ANCA and P-ANCA? - C-ANCA in Wegener granulomatosis- P-ANCA in PAN, Churg-Strauss and IBD
• What is antiphospholipid syndrome? Antiphospholipid antibody syndrome is a hypercoagulable state associated with a group of antibodies that are directed against phospholipids or cardiolipins.
• What are the lab results in antiphospholipid syndrome? - Antibodies»» lupus anticoagulant, anticardiolipin and anti-β‎ 2 glycoprotein 1- Elevated (APTT) - False-positive RPR or VDRL- Persistent antiphosphlolipid antibodies + clinical features is diagnostic
• What is the clinical presentation of antiphospholipid syndrome? - CLOTS: Coagulation defect (arterial/venous) Livedo reticularisObstetric (recurrent miscarriage) ThrombocytopeniaThrombotic tendency affects cerebral, renal, and other vessels.- Two first-trimester spontaneous abortions suggest antiphospholipid antibodies.
• How to manage antiphospholipid syndrome? - Anticoagulation if symptomatic- Initial venous thromboembolic events: 6 months warfarin with a target INR of 2-3 - Recurrent venous or arterial thromboembolic events: lifelong warfarin with target INR 2-3- If occurred whilst taking warfarin then increase target INR to 3-4
• What is RA? - Rheumatoid arthritis (RA) is a chronic inflammatory multisystemic disease with the main target being the synovium.- The intense joint inflammation that occurs has the potential to destroy cartilage and cause bone erosions and eventually deform the joint.
• Which antibodies is very specific for RA? Anti-CCP (cyclic citrullinated peptide)
• What causes RA and what is the usual age onset? - The cause of RA is unknown or- Hereditary factors (HLA-DR4 gene) - Reaction to an infectious agent (mycoplasma, parvovirus) in a susceptible host- Associated with smoking- Women affected 3× more than men - Age of onset usually age 35–50 (80%)
• Why RA is very rare in patients with HIV? - The predominant infiltrating cell is the T lymphocyte.- Diseases such as HIV, where T cells are decreased, will characteristically improve preexisting RA and this explains why RA is very rare in patients with HIV.
• Which cytokines mediate most of the pathogenic features of RA? TNF-a, IL-1 and IL-6
• Which criteria is required to diagnose RA? "Scores ≥6 are diagnostic"
• Which joints are never involved in RA? • DIPs • Joints of the lower back
• What are the main categories of clinical features of RA? - Constitutional Sx in ~70% of patients as fatigue, anorexia, weight loss, generalized weakness- Then arthritis (as mentioned in diagnosis criteria) - Extraarticular manifestations
• What are the extraarticular manifestations of RA? • Damage to the ligaments and tendons – Radial deviation of the wrist with ulnar deviation of the digits– Boutonnière deformity – Swan-neck deformity• Rheumatoid nodules – Initial event caused by focal vasculitis– 20–30% of patients with RA, usually occur in areas of mechanical stress (olecranon, occiput, Achilles tendon)– Methotrexate may flare this process• Syndromes– Felty syndrome (RA + splenomegaly + neutropenia) ...
• Investigations for RA include? General- CBC»» anemia - CRP and ESR Specific- Antibodies (RF or Anti-CCP) - X-ray- Synovial fluid analysis (inflammatory type»» 5,000–50,000) The diagnosis is based on the use of clinical criteria
• What are the X-ray findings in RA? "- Joint deformity - Cartilage destruction - Bone erosions- Periarticular osteopenia- Ulnar deviationPeriarticular erosions are most suggestive of rheumatoid arthritis"
• What is the most common extraarticular manifestation of RA? Rheumatoid nodules
• What are the options to manage RA symptoms? - NSAIDs (use selective COX-2 inhibitors as celecoxib in those with GI intolerance) - In acute exacerbations methylprednisolone intra-articular ± oral prednisolone if difficult symptoms- Surgery may relieve pain, improve function, and prevent deformityAll can be used briefly to control disease while waiting for DMARD to work.
• What are the disease-modifying antirheumatic drugs lines in management of RA? - Methotrexate, sulfasalazine, and hydroxychloroquine are 1st line (Leflunomide is another option)- Infliximab, etanercept, adalimumab are the 1st-line agents if methotrexate is contraindicated can be used as monotherapy.- Other combinations if above lines failed:» Methotrexate + rituximab» Methotrexate + tocilizumab» Abatacept
• What is the mechanism of action of each biological agent? - TNFα‎ inhibitors are infliximab, etanercept, adalimumab, golimumab and certolizumab - Anti CD-20 receptors is Rituximab- IL-6 receptor blocker is Tocilizumab- IL-1 receptor blocker is Anakinra- Inhibitor of T-cell co-stimulation is Abatacept
• Which DMARD is safe in pregnancy? Sulfasalazine
• What are the SEs of DMARDs? - Methotrexate—>pneumonitis (pre treatment CXR), oral ulcers, hepatotoxicity, teratogenic.- Sulfasalazine—>rash, ↓sperm count, oral ulcers, GI upset.- Leflunomide—>teratogenicity (♂ and ♀), oral ulcers, ↓BP, hepatotoxicity.- Hydroxychloroquine—>can cause retinopathy; pre treatment and annual eye screen required.
• Latent assessment and treatment for TB are required before using TNF inhibitors.
• What are the SEs of TNF inhibitors? - Sepsis- Disseminated TB- Opportunistic infections- Drug induced lupus (specifically associated with anti DS DNA Ab not anti histone Ab 🔥🔥🔥🔥)