Untitled Quiz

Study Notes

RA is a chronic systemic autoimmune disorder that primarily affects joints, resulting in symmetrical polyarthritis.

Predominantly affects females, with a female-to-male ratio of 3:1.
Commonly develops in individuals aged 20 to 40, with prevalence increasing with age.

Gender: Higher incidence before menopause for women; equal rates afterward suggest hormonal influence.
Familial Link: Increased incidence in individuals with a family history of RA.
Genetic Factors:
- HLA-DR4 and HLA-DRB1 0404/0401 increase susceptibility and severity risk.
- Other genes such as PTPN22, STAT4, and PADI-4 also contribute to risk.
Smoking: Identified as an environmental risk factor for seropositive RA.
Unknown Trigger: The specific triggering antigen in RA has yet to be identified.

Characterized by synovitis, leading to thickened synovial lining and inflammation.
Angiogenic cytokines promote new blood vessel formation in the synovium.
Formation of pannus, which proliferates over cartilage, causing erosions in bone and cartilage.

Articular manifestations lead to symmetric inflammatory polyarthritis, frequently involving joints such as MCP, PIP, wrist, elbow, knee, ankle, and MTP.
Morning stiffness lasting over 60 minutes for at least six weeks is typical.
Joint symptoms improve with use but worsen with inactivity (gelling phenomenon).
Characteristic hand deformities include ulnar deviation, swan neck, and boutonniere deformities.
Cervical spine involvement may lead to C1-C2 subluxation, necessitating imaging before tracheal intubation.

Peri-articular: Bursitis, tenosynovitis, muscle wasting, rheumatoid nodules.
Cardiac: Pericarditis, myocarditis, atherosclerosis, Raynaud's syndrome.
Pulmonary: Low glucose pleural effusion, interstitial lung disease, and Caplan syndrome.
Ocular: Episcleritis, scleritis, keratitis, uveitis, and Sjögren's syndrome.
Renal: Amyloid disease, analgesic nephropathy.
Neurological: Mononeuritis multiplex, cervical myelopathy, carpal tunnel syndrome.
Dermatological: Rheumatoid nodules in about 25% of cases, usually over pressure points.
Hematological: Anemia of chronic disease, thrombocytosis, Felty syndrome (RA with neutropenia and splenomegaly).
Vascular: Vasculitis, leg ulcers, nail fold infarcts, gangrene.

In young women with symmetric hand arthritis, consider RA, SLE, and viral infections.
RA is less likely if symptoms resolve within six weeks, favoring viral causes.
Diagnostic imaging may not differentiate early RA from SLE.

Positive serology is essential for RA diagnosis.
Radiology: Key findings include periarticular osteopenia, joint space narrowing, and juxtaarticular erosions, often beginning in the feet.
Laboratory Tests:
- Rheumatoid factor (RF): Not specific for RA, but present in some cases.
- Anti-CCP antibodies: More specific for RA; presence indicates risk for disease progression.
- Elevated ESR and CRP levels are frequent but not definitive.
- Synovial fluid analysis shows sterile fluid with high neutrophil counts in uncomplicated cases.

General: Monitor disease activity through history and standardized scores.
DMARDs:
- Methotrexate: First-line treatment with routine monitoring for side effects; contraindicated in renal and hepatic diseases.
- Sulfasalazine and Leflunomide: Other options for DMARD therapy with distinct monitoring and contraindications.
- Hydroxychloroquine: Needs yearly eye examinations due to retinal risk.
Corticosteroids: First-line treatment minimizing dosage; long-term monitoring for side effects.
NSAIDs: Useful for symptomatic relief but do not affect disease progression.
Biologic DMARDs:
- TNF-α inhibitors as second-line options; associated with increased risk of infections and malignancies.
- Monitoring includes both initial assessments and ongoing checks for side effects.

Early initiation of DMARDs is crucial to limit joint damage and improve quality of life.
Special consideration for treatment during pregnancy, favoring prednisone and hydroxychloroquine.