Sunday, 21 October 2007

Rheumatoid Arthritis

Rheumatoid Arthritis


Bilateral symmetrical arthropathy involving both hands

Spindling of the fingers due to swelling of the soft tissue at the MCJ and PIJ with sparing of the DIJ

Generalized wasting of the small muscles of the hand with wasting of the thenar and hypothenar eminence

There is deformity. Describe site

Swan neck

Boutonnière

Z shaped deformity

There is subluxation at the MCP with ulnar deviation of the fingers

No evidence of sinovitis

No features of carpel tunnel syndrome

No palpable rheumatoid nodules at the elbow

There is marked functional disability of both hands


What is the differential diagnosis?

Psoriatic arthropathy

Infection, bacterial, viral

Still disease

SLE

OA


What are the extra articular manifestations?

Occur in 30% of patients with RA

Lungs

Plural effusion

Plural nodules

Diffuse fibrosing alveolitis

Obstructive bronchiolitis

Vaculitis

Nail fold infarct

Cutaneous Vaculitis

Bowel infarction

Heart

Pericarditis

Aortic regurg

CNS

Mononuritis multiplux

Compressive arthropathy

Atlanto axial subluxation

Kidney

Amyloidosis

Eyes

Scleritis

Episcleritis

Scleromalasia perforance

Sicca syndrome

Spleen felty syndrome

How to investigate?

FBC

Inflammatory markers

Serology RF +ve in 75 %

X ray of the affected joints

Aspiration if effusion is present


What are the causes of anaemia?

Anaemia of chronic disease

IDA secondary to NSAID’s

Haemolytic anaemia

Pancytopenia secondary to felty syndrome

Bone marrow suppression secondary to treatment


What are the x ray finding?

Juxta articular osteoporosis

Loss of joint space

Bony erosion

Subluxation

Soft tissue thickening


What is the line of management?

NSAID’s

Control pain & stiffness

Act on cyclooxygenase pathway

DMD

Act through cytokines inhibition

Use early if sero +ve in presence of poor prognostic feature

Corticosteroids

Intra articular inj

Biologic

TNF inhibitors


What is the side effect of treatment?

NSAID’s

GI bleeding

Fluid retension

Interstitial nephritis

DMD

Methotrexate hepatotoxicity

Mouth ulcers

Bone marrow suppression

Pneumonitis

Sulphsalazine rash

Marrow suppression

Oligspermia

Biologics

Etarnecpt blood disorder

Reaction at the site of injection

Infleximab reaction of TB

What are the complications of RA?

Rupture tendon

Joint infection

Ruptured joint

Spinal cord compression

Amyloidosis


What are the types of presentations?

Palindromic

Transient

Remitting

Chronic persistant

Rapidly progressive


What are the poor prognostic features?

FR +ve

Extra articular feature

HLA DR4

Female

Early erosions

Insidious onset

Anaemia of old age

High inflammatory markers

read about RA new NICE guidelines Feb 2009



95 comments:

  1. causes of occular involvement in RA:
    1-episcleritis/scleritis/scleromalcia
    2-sjogren's syndrome
    3-cataract secondary to steriods therapy
    4-retinopathy secondary to chloroquine
    5-extraocular muscle tendon synovitis
    6-extraocular muscle paralysis secondary to penicilamine induced myaethenia
    7-extraocular muscle paralysis secondary to mononuritis multiplex

    ReplyDelete
  2. causes of renal involvement in RA:
    1-acute tubulointerstitial nephritis secondary to NSAIDs
    20renal papillary necrosis secondary to analgesic abuse
    3-renal amyloid
    4-membraneous nephropathy secondary to gold or penicillamine
    5-minimal change glumerulonephritis complicating NSAIDs

    ReplyDelete
  3. cause of respiratory involvement in RA:
    1-cricoarytenitis
    2-pleural effusion
    3-pulmonary fibrosis
    4-bronchiolitis
    5-pneumonitis
    6-pulmonary nodules
    7-Caplan's syndrome

    ReplyDelete
  4. treatment:
    It is now well established that early intensive intervention with combination therapy at the outset improves outcomes in RA. National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2009) regarding the management of RA state:

    “In people with newly diagnosed active RA, offer a combination of disease-modifying anti-rheumatic drugs (DMARDs) (including methotrexate and at least one other DMARD, plus short term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms.

    In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate, start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD”

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