Autoimmunity and ANA Testing
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Questions and Answers

What clinical features may indicate a high pre-test probability of rheumatic disease prompting an ANA test?

  • Photosensitivity and discoid rash (correct)
  • Joint stiffness and swelling
  • Fever and fatigue
  • Migratory pain in the limbs

What does a positive ANA result suggest in the context of autoimmune diseases?

  • It may prompt further testing for specific antibodies. (correct)
  • It confirms the diagnosis of rheumatoid arthritis.
  • It is indicative of high disease activity.
  • It confirms the absence of rheumatic disease.

What is the significance of a negative ANA test result?

  • It does not exclude the possibility of rheumatic disease. (correct)
  • It means the patient has a healthy immune system.
  • It is definitive for the absence of all autoantibodies.
  • It confirms that the patient has no rheumatic disease.

Which autoantibody is specifically associated with systemic lupus erythematosus (SLE) but found in less than one-third of cases?

<p>Anti-SM (D)</p> Signup and view all the answers

Which laboratory assessment should be combined with ANA testing for a more complete evaluation of rheumatoid arthritis?

<p>Full blood examination (FBE) (C)</p> Signup and view all the answers

What is the main characteristic of oligoarticular Still's disease?

<p>Affects 4 or fewer joints, usually medium and large joints (D)</p> Signup and view all the answers

What is a potential complication associated with systemic Still's disease?

<p>Amyloidosis (A)</p> Signup and view all the answers

Which type of Still's disease is characterized by symmetrical involvement of 5 or more joints?

<p>Polyarticular (RhF negative) (C)</p> Signup and view all the answers

What does the presence of HLA B27 indicate in enthesitis related arthritis?

<p>A family history of HLA B27 related disease (A)</p> Signup and view all the answers

Which of the following is NOT a common joint affected by oligoarticular Still's disease?

<p>Cervical spine (B)</p> Signup and view all the answers

What additional symptoms are associated with systemic Still's disease?

<p>High fever and transient rash (A)</p> Signup and view all the answers

Which type of Still's disease is most likely to mimic adult rheumatoid arthritis?

<p>Polyarticular (RhF positive) (B)</p> Signup and view all the answers

What characteristic distinguishes psoriatic arthritis from other types of Still's disease?

<p>Associated with dactylitis or nail changes (C)</p> Signup and view all the answers

What is the typical age range for the peak prevalence of polymyalgia rheumatica?

<p>70-80 years (C)</p> Signup and view all the answers

Which of the following is a common laboratory finding in patients with polymyalgia rheumatica?

<p>Elevated CRP (D)</p> Signup and view all the answers

What is the recommendation for treatment if there is not a 70% improvement in symptoms after corticosteroid therapy?

<p>Refer to a rheumatologist (C)</p> Signup and view all the answers

What genetic markers are associated with polymyalgia rheumatica?

<p>HLA-DR4 and HLA-DRB1 (A)</p> Signup and view all the answers

Which imaging technique typically shows bilateral sub-acromial/deltoid bursitis in patients with polymyalgia rheumatica?

<p>Ultrasound (USS) (D)</p> Signup and view all the answers

What is the lifetime risk of developing polymyalgia rheumatica for women?

<p>2.4% (D)</p> Signup and view all the answers

Which of the following conditions is NOT a known increased risk following a diagnosis of polymyalgia rheumatica?

<p>Persistent asthma (B)</p> Signup and view all the answers

What type of anemia is typically found in patients with polymyalgia rheumatica?

<p>Normocytic anemia (B)</p> Signup and view all the answers

What is the primary effect of colchicine in the management of gout?

<p>Preventing future gout attacks by managing inflammation (B)</p> Signup and view all the answers

Which therapy is recommended to lower uric acid levels in gout patients?

<p>Allopurinol (C)</p> Signup and view all the answers

What should be monitored when initiating allopurinol treatment?

<p>Rash, fever, and renal failure (C)</p> Signup and view all the answers

When should allopurinol not be started?

<p>During an acute gout attack (B)</p> Signup and view all the answers

Which medication is specifically indicated for patients with renal impairment?

<p>Febuxostat (A)</p> Signup and view all the answers

How does febuxostat help manage gout?

<p>By inhibiting xanthine oxidase to reduce uric acid levels (C)</p> Signup and view all the answers

What are indications for urate-lowering therapy?

<p>Presence of gouty tophi (A)</p> Signup and view all the answers

What is a potential consequence of initiating allopurinol treatment?

<p>Exacerbation of an existing acute attack (B)</p> Signup and view all the answers

Which of the following viruses is associated with high rates of arthritis?

<p>Parvovirus B19 (A), Ross River (C)</p> Signup and view all the answers

What is the most common form of joint involvement in Ross River virus infections?

<p>Symmetrical involvement of the wrists and knees (B)</p> Signup and view all the answers

Which symptom is least commonly associated with Ross River virus infections?

<p>Shortness of breath (D)</p> Signup and view all the answers

Which treatment is commonly recommended for managing symptoms of Ross River virus arthralgia?

<p>Gentle physical therapy (C)</p> Signup and view all the answers

What is the triad of symptoms associated with reactive arthritis?

<p>Urethritis, conjunctivitis, arthritis (A)</p> Signup and view all the answers

Which causative organism is noted to be associated with reactive arthritis?

<p>Chlamydia (D)</p> Signup and view all the answers

Which characteristic is true about the arthritis caused by the Ross River virus?

<p>It may last for years but remains non-destructive (D)</p> Signup and view all the answers

What is the incidence rate of chronic autoimmune inflammatory joint disease in children and adolescents?

<p>1 in 1000 (B), 1 in 2000 (D)</p> Signup and view all the answers

Which of the following conditions can mimic Juvenile Idiopathic Arthritis (JIA)?

<p>Septic arthritis (A)</p> Signup and view all the answers

What is the most significant complication associated with oligoarticular JIA?

<p>Uveitis (D)</p> Signup and view all the answers

Which laboratory test is not initially included in the investigations for JIA?

<p>Bone density scan (B)</p> Signup and view all the answers

Which treatment has shown dramatic improvement in non-systemic JIA?

<p>Anti-TNF agents (C)</p> Signup and view all the answers

What is the peak incidence age range for rheumatoid arthritis?

<p>60-70 years (D)</p> Signup and view all the answers

Which of the following is NOT a classification criterion for rheumatoid arthritis?

<p>Swelling of fewer than three joint areas (A)</p> Signup and view all the answers

What is the best environmental link found related to rheumatoid arthritis?

<p>Tobacco smoking (D)</p> Signup and view all the answers

Which of the following conditions is most often associated with linear growth abnormalities in children with JIA?

<p>Systemic JIA (B)</p> Signup and view all the answers

Flashcards

ANA test use in Rheumatology

Ordered when high suspicion of a rheumatic disease exists, it assesses for antinuclear antibodies. However, it is not specific for any particular rheumatic disease.

Clinical symptoms associated with high ANA scores

Symptoms like arthritis, photosensitivity, skin rashes, hair loss, dry eyes and mouth, mouth sores, and more.

ANA test's limitations

A negative ANA test doesn't rule out rheumatic disease. It's sensitive but not specific. A positive result often requires further testing.

Follow-up testing after a positive speckled ANA

Further testing (like ENA) is needed to pinpoint the specific type of antinuclear antibody present.

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Important combined tests with a positive ANA

Tests like anti-CCP (for RA), a complete blood count (FBE), urinalysis, and anti-dsDNA are often conducted to provide a comprehensive view of the possible rheumatic disease and its potential complications.

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Still's Disease Diagnosis

Diagnosis of Still's disease is made by ruling out other conditions.

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Still's Disease Cause

Suspected cause of Still's disease may be from infection or environment.

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Still's Disease Joint Damage

Inflammation (synovitis) in Still's disease can harm the joints.

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Oligoarticular Still's Disease

A form of Still's disease affecting 4 or fewer joints.

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Viral arthritis types

Viral infections can cause different levels of arthritis. Ross River virus causes very high rates of arthritis; while those caused by Parvovirus B19 and Rubella are higher. Hepatitis B, Hepatitis C lead to moderate levels.

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Polyarticular Still's (RhF-)

Still's disease that affects 5+ joints without Rh factor.

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Ross River Virus symptoms

Ross River Virus causes joint pain (95%), lasting more than a month (90%), fatigue (90%), arthralgia (80%), myalgia (60%), and rash (50%). It often involves symmetrical joint involvement in peripheral joints, with ankle, knee, wrist, and hand being most common.

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Polyarticular Still's (RhF+)

Still's disease involving 5+ joints, with Rh factor present.

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Systemic Still's Disease

Still's disease with fever, rash, swollen lymph nodes, & organs (liver/spleen).

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Ross River Virus Management

Ross River Virus treatment is non-specific. Rest during the acute stage, gentle physical therapy, simple analgesia, and NSAIDs are common.

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Reactive arthritis cause

Reactive arthritis is triggered by infections, like those of the urogenital or gastrointestinal tracts.

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Enthesitis-related Still's

Still's type with inflammation at the connection of tendons, ligaments, and bone.

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Reactive arthritis triad

Reactive arthritis often involves a combination of three key symptoms: urethritis, conjunctivitis (eye inflammation), and arthritis.

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Reactive Arthritis organisms

Common causes of reactive arthritis include Chlamydia, Yersinia, Shigella and Campylobacter. Less frequently, other organisms like C.diff, Mycoplasma,and TB are possible causes.

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Juvenile Idiopathic Arthritis (JIA)

Chronic, autoimmune and inflammatory joint disease frequently starting before age 16. It is defined by persistent arthritis of unknown cause lasting at least 6 weeks.

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JIA - Frequency

JIA is a relatively rare rheumatic disease occurring in approximately 1/1000-2000 individuals.

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JIA Mimickers

Conditions that mimic the symptoms of Juvenile Idiopathic Arthritis (JIA), making diagnosis challenging.

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Septic Arthritis

A bacterial infection of a joint, often causing sudden onset of pain, swelling, and redness. It's a serious mimicker of JIA.

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What is Uveitis?

Inflammation of the middle layer of the eye (uvea) that can occur as a complication of JIA, potentially leading to vision loss.

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Uveitis Risk Factors

Children with oligoarticular JIA (affecting few joints), under 7 years old, and positive ANA test are at highest risk for developing uveitis.

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RA Prevalence

Rheumatoid arthritis (RA) affects about 1% of the population, with women being twice as likely to develop it.

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RA Genetics

A genetic link exists with HLA-DR4, a gene present in 20-30% of the normal population, suggesting a predisposition to RA.

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RA Environmental Triggers

Tobacco smoking, obesity, and silica exposure have been identified as environmental factors that could trigger RA.

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RA Peak Incidence

The peak incidence of RA occurs between the ages of 60 and 70 years.

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Colchicine for Gout

Colchicine helps prevent future gout attacks by reducing inflammation, but it doesn't address the underlying uric acid issue.

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Uric Acid Lowering Therapy

Medications like allopurinol and febuxostat are used to reduce uric acid levels in the blood, which is the root cause of gout.

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Allopurinol for Gout

Allopurinol is a medication that prevents the body from producing too much uric acid. It's often used to prevent gout attacks and tophi formation.

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Febuxostat for Gout

Febuxostat is another medication that lowers uric acid levels by inhibiting the enzyme xanthine oxidase.

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When to Start Urate Lowering Therapy?

Urate lowering therapy is usually recommended for patients with frequent gout attacks (2+ per year), tophi, gout with kidney issues, and high urinary uric acid excretion.

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Starting Allopurinol

Start allopurinol at a low dose and gradually increase it over time. Don't start during an acute gout attack.

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Allopurinol Monitoring

Monitor for potential side effects of allopurinol, including rash, fever, liver problems, and kidney problems.

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Preventing Gout Attacks During Allopurinol Initiation

Consider using NSAIDs or colchicine during the initial weeks of allopurinol to prevent gout attacks.

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What is Polymyalgia Rheumatica (PMR)?

PMR is an inflammatory condition characterized by aching and morning stiffness primarily affecting the shoulders, hips, and neck, often accompanied by fatigue, loss of appetite, and weight loss. It predominantly affects adults over 50, with prevalence increasing with age.

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Who is most likely to develop PMR?

PMR is almost exclusively found in adults over 50 years old, with the highest incidence between 70-80 years of age. The prevalence increases with advancing age.

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What are the typical PMR symptoms?

Common symptoms include bilateral shoulder girdle pain and prolonged early morning stiffness (lasting over 45 minutes, often for hours). Hip involvement is very common, with neck, back, and buttock pain also frequently reported. Distal manifestations, like wrist and knee arthritis, are less frequent.

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How does PMR differ from Rheumatoid Arthritis?

PMR is typically more sensitive to prednisolone treatment than rheumatoid arthritis. It is also characterized by a lack of joint destruction.

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What are the common blood test findings in PMR?

Elevated ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) are common, although ESR can be normal or mildly elevated. A normocytic anemia may be present. ANA, Rh factor, and CCP are typically negative, though they may increase with age. LFT (liver function tests) and ALP (alkaline phosphatase) may be elevated, particularly in those with Giant Cell Arteritis.

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What are the imaging findings in PMR?

X-rays are usually normal. Ultrasound and MRI may show bilateral sub-acromial/deltoid bursitis.

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How is PMR treated?

Corticosteroids are the mainstay treatment. If symptoms don't improve by 70% with corticosteroids, referral to a rheumatologist is recommended to consider methotrexate or TNF-alpha blockers.

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What is the prognosis for PMR?

The prognosis for PMR is usually good. It can, however, be the initial presentation of more serious conditions (10% of patients), including Giant Cell arteritis, rheumatoid arthritis, spondyloarthropathy, SLE, vasculitis, hyperparathyroidism, amyloidosis, and multiple myeloma.

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Study Notes

Rheumatology For Sports Physicians - Investigations

  • ANA (Antinuclear Antibodies): Ordered when high pre-test probability of rheumatic disease is suspected.
    • Clinical indicators: Includes arthritis, photosensitivity, discoid rash, alopecia, dry eyes, dry mouth, mouth ulcers, sclerodactyly, Raynaud's.
    • Lab findings prompting ANA: Hemolytic anemia, thrombocytopenia, lymphoma, hypergammaglobulinemia, hematuria, or proteinuria.
    • Significance: Not associated with disease activity.
    • Prevalence: 40% of the population has low titers, and 5% of healthy individuals have moderate titers.
    • Factors affecting rate: Slightly higher in women and the elderly.
    • Negative result implication: A negative result does not rule out rheumatic disease; it is sensitive but not specific.
  • ENA (Extractable Nuclear Antibodies): If positive speckled ANA.
    • Anti-SM antibody: SLE-specific, but only present in less than a third of SLE cases.
    • Anti-SSA/SSB (Ro/La antibodies): Associated with Sjögren's syndrome and cutaneous lupus, and can indicate congenital heart block.
    • Homogeneous ANA: Anti-dsDNA for SLE, which can fluctuate with disease activity.
  • Other tests to combine with ANA: Anti-CCP (for rheumatoid arthritis), complete blood count (FBE) to check for cytopenias in SLE, urinalysis for proteinuria (renal manifestations), serum complement (decreased in immune complex-mediated diseases like SLE) and serum immunoglobulins (raised in Sjögren's).

Lyme Arthritis (LA)

  • Description: First described in 1977; Borrelia burgdorferi isolated in 1982.
  • Geographic distribution: Most common vector-borne illness in North America and Europe; high prevalence in the Northeast and Upper Midwest United States.
  • Vector: Ixodes (black-legged deer tick)
  • Clinical presentation (LA): Occurs 4 days to 2 years after the initial erythema migrans rash. Usually presents as monoarthritis (most commonly knee) or oligoarthritis. Commonly large effusions are present.

Viral Arthritis

  • General Description: Usually presents as polyarthritis, except for HIV and HCV, in which 20% of cases are oligoarthritis, while 80% of cases are polyarthritis.
  • Ross River (Group A Arbovirus): Most commonly involves the ankle, knee, wrist, and hands.
    • 95% of cases experience Joint pain
    • 90% of cases experience >1 month duration of joint pain.
    • 90% of cases experience fatigue.
    • 80% of cases experience arthralgia
    • 60% of cases experience myalgia
    • 50% of cases experience rash
    • 50% of cases experience fever
  • Other Viral Arthritis: Parovirus B19 (slap cheek syndrome), Rubella (rash on face, hands, and feet).

Reactive Arthritis

  • Description: Inflammatory condition.
  • Etiology: Postbacterial, urogential, or gut infections.
  • Clinical Characteristics: Asymmetric arthritis usually involving lower limbs. Frequently associated with urethritis, conjunctivitis, and enthesitis.
  • HLA-B27: Associated with 80–90% Shigella, 79–80% Yersinia, and 40–55% Chlamydia infections.
  • Duration: Typically 4–12 months, sometimes longer.

Reactive Arthritis - Assessment Criteria

  • Parameters : Episode of arthritis, urethritis and/or cervicitis, or bilateral conjunctivitis, and multiple episodes of arthritis, conjunctivitis and urethritis.
  • Sensitivity : Ranges from 51%-86% depending on parameter.
  • Specificity : Ranges from 96%- 98% depending on parameter.

Juvenile Idiopathic Arthritis (JIA)

  • Definition: Chronic autoimmune inflammatory joint disease common in children and adolescents.
  • Duration: Lasting 6 weeks or longer which begins before 16 years of age
  • Types:
  • Oligoarticular JIA: Affects 4 or fewer joints. Medium to large joints predominantly
  • Polyarticular JIA (RhF-negative): Affects 5 or more joints. Predominantly small to large joints
  • Polyarticular JIA (RhF-positive): Affects 5 or more joints. Predominantly small to large joints
  • Systemic JIA: Chronic arthritis associated with systemic features. Including high fever, transient rash (salmon), lymphadenopathy, and hepatosplenomegaly, bony ankylosis, and possibly amyloidosis.
  • Enthesitis-related/associated: Previously called juvenile spondyloarthropathy and can also manifest as lower axial involvement (including Spine, Sacroiliac joints(SIJ)), and bone ankylosis.

Rheumatoid Arthritis (RA)

  • Prevalence: 1% prevalence.
  • Clinical Features: Symmetrical arthritis affecting the wrists, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hands, and frequently affecting the metatarsophalangeal (MTP) joints of the feet.
  • Morning stiffness: Often lasting for more than 1 hour, is a cardinal feature.
  • Systemic features: Flu-like symptoms, fatigue, malaise, and weight loss.
  • Possible involvement of C-spine: 30-50% of cases.
  • Clinical signs: swan neck deformity, MCPJ dorsally: Synovial hypertrophy and cysts, hyperextension of IPJ, Z deformity, Ulnar deviation, Boutonniere deformity, and Swan neck deformity.

Additional Notes

  • Acute-phase reactants (ESR and CRP): Often elevated in active RA
  • Rheumatoid factor (RF): Present in 60–70% of RA patients, indicative of seropositivity.
  • Anti-citrullinated protein antibodies (ACPA): More specific for RA than RF, often detected early in the disease.
  • X-rays: Can reveal joint damage (erosions) and erosions particularly noticeable in the hands and wrist.
  • MRI and Ultrasound: Detect inflammation, synovitis, and erosions earlier than X-rays.

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Rheumatology For Sports Physicians PDF

Description

This quiz explores key concepts related to antinuclear antibody (ANA) testing in the context of autoimmune diseases. Participants will learn about the clinical features that indicate a high probability of rheumatic disease, the implications of positive and negative ANA results, and the specific autoantibodies associated with conditions like systemic lupus erythematosus. Enhance your understanding of the diagnostic process in rheumatology.

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