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What is the first-line treatment for rheumatoid arthritis?
What is the first-line treatment for rheumatoid arthritis?
Liver failure is considered a minor complication of methotrexate treatment for rheumatoid arthritis.
Liver failure is considered a minor complication of methotrexate treatment for rheumatoid arthritis.
False
What is the maximum weekly dosage of methotrexate for treating rheumatoid arthritis?
What is the maximum weekly dosage of methotrexate for treating rheumatoid arthritis?
20 mg
The boolean definition of remission in rheumatoid arthritis includes a tender joint count of less than or equal to ______.
The boolean definition of remission in rheumatoid arthritis includes a tender joint count of less than or equal to ______.
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Match each medication with its potential complication:
Match each medication with its potential complication:
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Which of the following is a clinical feature of non-radiographic axial spondyloarthritis?
Which of the following is a clinical feature of non-radiographic axial spondyloarthritis?
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The absence of rheumatoid factor is a characteristic of spondyloarthritis.
The absence of rheumatoid factor is a characteristic of spondyloarthritis.
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What percentage of patients may show radiographic features of sacroiliitis within 5-10 years?
What percentage of patients may show radiographic features of sacroiliitis within 5-10 years?
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The most common extracellular manifestation of spondyloarthritis is __________.
The most common extracellular manifestation of spondyloarthritis is __________.
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Match the following features of axial spondyloarthritis with their correct descriptions:
Match the following features of axial spondyloarthritis with their correct descriptions:
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Which of the following is the most common complication of Radiographic Axial Spondyloarthritis?
Which of the following is the most common complication of Radiographic Axial Spondyloarthritis?
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HLA B27 is associated with 50% of cases of Radiographic Axial Spondyloarthritis.
HLA B27 is associated with 50% of cases of Radiographic Axial Spondyloarthritis.
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What age group is most commonly affected by Radiographic Axial Spondyloarthritis?
What age group is most commonly affected by Radiographic Axial Spondyloarthritis?
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The classic symptom of morning stiffness lasts for at least _____ minutes in Radiographic Axial Spondyloarthritis.
The classic symptom of morning stiffness lasts for at least _____ minutes in Radiographic Axial Spondyloarthritis.
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Match the following inflammatory mediators with their corresponding use:
Match the following inflammatory mediators with their corresponding use:
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Which symptom is associated with Keratoderma blennorrhagicum?
Which symptom is associated with Keratoderma blennorrhagicum?
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Dactylitis is characterized by painful swollen digits.
Dactylitis is characterized by painful swollen digits.
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What is the HLA B-27 association percentage in cases of acute sterile arthritis?
What is the HLA B-27 association percentage in cases of acute sterile arthritis?
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Asymmetrical peripheral arthritis often begins at the __________ joint.
Asymmetrical peripheral arthritis often begins at the __________ joint.
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Match the following clinical manifestations with their descriptions:
Match the following clinical manifestations with their descriptions:
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What is the most common pleural complication associated with rheumatoid arthritis?
What is the most common pleural complication associated with rheumatoid arthritis?
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Interstitial lung disease (ILD) associated with rheumatoid arthritis primarily affects the upper lobes of the lungs.
Interstitial lung disease (ILD) associated with rheumatoid arthritis primarily affects the upper lobes of the lungs.
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What is the characteristic finding in the pleural fluid analysis for pleural effusion in rheumatoid arthritis?
What is the characteristic finding in the pleural fluid analysis for pleural effusion in rheumatoid arthritis?
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Caplan syndrome is characterized by RA, synovitis, and cavitating nodules in the ______.
Caplan syndrome is characterized by RA, synovitis, and cavitating nodules in the ______.
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Match the lung conditions associated with rheumatoid arthritis to their descriptions:
Match the lung conditions associated with rheumatoid arthritis to their descriptions:
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Which condition is NOT associated with upper lobe interstitial lung disease (ILD)?
Which condition is NOT associated with upper lobe interstitial lung disease (ILD)?
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An MRI STIR sequence is used to identify hyperintensities with conclusive results.
An MRI STIR sequence is used to identify hyperintensities with conclusive results.
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What is the highest grade of joint involvement in X-ray findings related to ankylosing spondylitis?
What is the highest grade of joint involvement in X-ray findings related to ankylosing spondylitis?
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In osteoporosis, the risk is ranked as RA > AS > __________ > SLE.
In osteoporosis, the risk is ranked as RA > AS > __________ > SLE.
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What does the Dagger sign indicate in the context of spondyloarthritis?
What does the Dagger sign indicate in the context of spondyloarthritis?
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Match the following X-ray grades with their descriptions:
Match the following X-ray grades with their descriptions:
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The Modified Schober Test measures the range of motion in the cervical spine.
The Modified Schober Test measures the range of motion in the cervical spine.
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What is the minimum normal measurement of A to B in the Modified Schober Test?
What is the minimum normal measurement of A to B in the Modified Schober Test?
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The primary treatment for non-radiological axial SPA includes ______ and physiotherapy.
The primary treatment for non-radiological axial SPA includes ______ and physiotherapy.
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Match the following diagnosis signs with their descriptions:
Match the following diagnosis signs with their descriptions:
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Which of the following is a characteristic of Diffuse Idiopathic Skeletal Hyperostosis (DISH)?
Which of the following is a characteristic of Diffuse Idiopathic Skeletal Hyperostosis (DISH)?
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Reactive arthritis is characterized by urethritis, arthritis, and conjunctivitis.
Reactive arthritis is characterized by urethritis, arthritis, and conjunctivitis.
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What is the most common infectious cause of reactive arthritis worldwide?
What is the most common infectious cause of reactive arthritis worldwide?
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In reactive arthritis, the male to female ratio is approximately _____ for genitourinary infections.
In reactive arthritis, the male to female ratio is approximately _____ for genitourinary infections.
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Match the gastrointestinal infections with their associated prevalence in reactive arthritis:
Match the gastrointestinal infections with their associated prevalence in reactive arthritis:
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Which condition is characterized by groin pain, fever, and splenomegaly?
Which condition is characterized by groin pain, fever, and splenomegaly?
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Scleritis in RA and SLE is always associated with visual loss.
Scleritis in RA and SLE is always associated with visual loss.
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What is the most common cause of death in patients with Rheumatoid Arthritis-related cardiovascular conditions?
What is the most common cause of death in patients with Rheumatoid Arthritis-related cardiovascular conditions?
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RA is associated with __________ due to chronic inflammation.
RA is associated with __________ due to chronic inflammation.
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Match the following conditions with their associated findings:
Match the following conditions with their associated findings:
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Which of the following is a common ocular finding in both RA and SLE?
Which of the following is a common ocular finding in both RA and SLE?
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Leukopenia is not commonly associated with autoimmune conditions like RA.
Leukopenia is not commonly associated with autoimmune conditions like RA.
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In terms of vascular findings, which type of vasculitis is noted in patients with RA?
In terms of vascular findings, which type of vasculitis is noted in patients with RA?
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Which of the following drugs is a dihydroorotate dehydrogenase inhibitor?
Which of the following drugs is a dihydroorotate dehydrogenase inhibitor?
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Leflunomide has a mechanism involving the blockade of folic acid synthesis.
Leflunomide has a mechanism involving the blockade of folic acid synthesis.
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Name a biological agent that lowers TNF-α levels.
Name a biological agent that lowers TNF-α levels.
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Anakinra is ______ in India.
Anakinra is ______ in India.
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Match the following small molecule JAK inhibitors with their degree of inhibition:
Match the following small molecule JAK inhibitors with their degree of inhibition:
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Which biological agent is categorized as a fusion molecule with the least side effects?
Which biological agent is categorized as a fusion molecule with the least side effects?
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Hydroxychloroquine (HCQ) acts as a toll-like receptor inhibitor.
Hydroxychloroquine (HCQ) acts as a toll-like receptor inhibitor.
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What are the routes of administration for biological agents in RA management?
What are the routes of administration for biological agents in RA management?
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Which of the following is NOT considered an extraarticular manifestation of rheumatoid arthritis?
Which of the following is NOT considered an extraarticular manifestation of rheumatoid arthritis?
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Rheumatoid nodules are commonly found in juvenile idiopathic arthritis (JIA).
Rheumatoid nodules are commonly found in juvenile idiopathic arthritis (JIA).
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What is the most common extra-articular manifestation of rheumatoid arthritis?
What is the most common extra-articular manifestation of rheumatoid arthritis?
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_________ is a condition characterized by a painful bony prominence at the big toe joint.
_________ is a condition characterized by a painful bony prominence at the big toe joint.
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Match the following lower limb deformities with their descriptions:
Match the following lower limb deformities with their descriptions:
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Study Notes
Diagnosis and Treatment of Rheumatoid Arthritis (RA)
- Diagnosis: RA is diagnosed based on clinical presentation and confirmed with blood tests and imaging.
- Bridge Therapy: Steroids are used to manage active inflammation while waiting for disease-modifying antirheumatic drugs (DMARDS) to take effect (typically 6-8 weeks).
- First-Line Treatment: Methotrexate (MTX) is the primary treatment for RA, typically administered weekly in doses ranging from 5mg to 20mg.
- Methotrexate Complications: Common side effects include mucositis, oral ulcers, and hair loss. More serious complications include bone marrow suppression, liver failure (monitor liver function tests), and hypersensitivity pneumonitis.
-
Assessing Response to Treatment: After 3 months of treatment, remission is defined as:
- Tender joints ≤ 1
- Swollen joints ≤ 1
- C-reactive protein ≤ 1
- Patient global assessment ≤ 1
- Continued Treatment: If there is an adequate response, methotrexate is continued.
- Alternative Treatment: If there is not an adequate response, other medications like sulfasalazine (g-6-pd deficiency) are added, or alternative medications like TNF-α inhibitors or JAK inhibitors are considered.
- Hydroxychloroquine: It is typically used in doses of 5mg/kg, and common side effects include corneal complications, while retinal complications are more dangerous and known as "bulls-eye maculopathy".
Spondyloarthritis (SpA)
-
Classification: SpA is broadly categorized into axial and peripheral types:
-
Axial SpA: Primarily affects the spine and sacroiliac joints.
- Radiographic axial SpA: Also called ankylosing spondylitis (AS)
- Non-radiographic axial SpA: No radiographic evidence of sacroiliitis, but may have MRI evidence.
-
Peripheral SpA: Affects joints in the periphery, including the knee, elbow, and other peripheral joints.
- Reactive Arthritis (ReA): Triggered by bacterial infections.
- Psoriatic Arthritis: Associated with psoriasis.
- IBD (Enteropathic) Arthritis: Relates to inflammatory bowel disease.
-
Axial SpA: Primarily affects the spine and sacroiliac joints.
-
Features:
- HLA-B27 Association: Present in varying degrees, suggesting genetic predisposition.
- Extra-articular Manifestations: Frequently involves the eye, most commonly acute anterior alternating asymmetric uveitis (4f uveitis).
- Familial Aggregation: Strong familial tendency.
- Absence of Rheumatoid Factor (RF): Distinct from RA.
- Lack of Subcutaneous Nodules: Unlike RA, which often presents with subcutaneous nodules.
Axial Spondyloarthritis
Non-Radiographic Axial SpA
-
Clinical Features:
- Inflammatory back pain: Pain worsens with rest and improves with activity.
- Alternating buttock pain: Due to sacroiliitis.
- Deep low back pain: A characteristic symptom.
-
Radiographic Features (5-10 years): Radiographic signs of sacroiliitis may develop over time.
- Syndesmophytes: Bony outgrowths on the vertebral margins.
- Bony ankylosis: Fusion of joints, leading to stiffness.
- Bamboo spine: A characteristic radiographic appearance of fused vertebral bodies.
- Spinal fracture: A possible complication.
- No Radiographic Evidence: No radiographic signs of sacroiliitis but may have MRI findings of active inflammation.
- HLA-B27: May have this association.
Radiographic Axial SpA
-
Pathogenesis:
- Inflammatory granulation tissue: Forms at the site of inflammation.
- Erosion of annulus fibrosis and nucleus pulposus: Damage to the intervertebral disc.
- Calcification of peripheral fibers of annulus fibrosis: Formation of syndesmophytes.
-
Complications:
- Spinal fracture: Particularly at C5-C6.
-
Inflammatory Mediators:
- TNF-α: A key pro-inflammatory cytokine.
- IL-17 and IL-23: Involved in promoting inflammation.
-
Presentation:
- Synovitis: Inflammation of the synovial lining of joints.
- Sacroiliitis: Inflammation of the sacroiliac joints, a hallmark of the condition; typically bilateral.
- Male to Female Ratio: Prevalence is higher in males (3:1).
- Age: Usually affects younger adults, starting in their early 20s.
- HLA-B27 Association: Present in approximately 90% of cases.
-
Inflammatory Back Pain Signs:
- Onset: Usually before age 45.
- Duration: Chronic pain lasting for more than 3 months.
- Location: Primarily in the lower back.
- Alternating buttock pain: Due to sacroiliitis.
- Waking up from sleep due to back pain: Pain often disturbs sleep.
- Morning stiffness: Lasting for at least 30 minutes.
-
Extra-articular Features:
- Anterior uveitis: Inflammation of the uvea, the middle layer of the eye; the most common.
- Cardiovascular (CVS): Potential for aortic regurgitation, ascending aortitis, and conduction blocks.
- Renal: Secondary IgA nephropathy.
- Lungs: Upper lobe interstitial lung disease (NSIP).
- Chest pain: Caused by enthesitis at the costochondritis or manubriosternal joint.
- Ascending thoracic spine: Progression of inflammation to the thoracic spine.
- Osteoporosis: Bone loss due to chronic inflammation.
-
Enthesitis:
- Inflammation at the insertion points of tendons, ligaments, capsules, and fascia.
- Common sites: Achilles tendinitis, plantar fasciitis, costochondritis.
-
Bony Ankylosis:
- Fusion of joints, leading to stiffness.
- Bamboo spine: Characteristic radiographic appearance.
- Square wave vertebra: Loss of the normal concave shape of vertebrae.
- Gliding of vertebra over one another: A result of joint fusion.
Spondyloarthritis: Arthritis
-
Acute Sterile Arthritis:
- Inflammation of a joint without an identifiable bacteria present in the joint fluid.
- Bacteria are detected inside monocytes in the synovium using PCR.
- HLA-B27 association: Present in 50-70% of cases.
-
Asymmetrical Peripheral Arthritis:
- Affects joints in the periphery, often starting at the knee.
- More common to have oligoarthritis (involvement of a few joints) than monoarthritis (involvement of a single joint).
- Additive: The involvement of joints is progressive.
- Painful Joints: Pain is a common symptom.
Spondyloarthritis: Clinical Manifestations
- Synovitis: Inflammation of the synovial lining of joints.
- Predominant Enthesitis: Inflammation at tendon and ligament insertion points.
- Dactylitis: Sausage-like swelling of the fingers or toes.
Spondyloarthritis: Inflammatory Arthritis of Knee Joint:
- Inflammation of the knee joint, a common site of involvement.
Spondyloarthritis: Enthesitis (Achilles Tendinitis)
- Inflammation at the Achilles tendon insertion point, a classic sign in SpA.
Spondyloarthritis: Mucocutaneous Manifestations
- Keratoderma blennorrhagicum: Hyperkeratotic, crusty vesicles on the palms and soles, often painless.
- Circinate balanitis: Shallow, erythematous ulcers on the glans penis, typically painless.
- Note: Palmo-plantar psoriasis can be differentiated from Keratoderma blennorrhagicum.
Spondyloarthritis: Axial Involvement of Reactive Arthritis
- Asymmetric Saccharoliitis: Inflammation of the sacroiliac joints, but often affecting one side more than the other.
- Syndesmophytes: Bony growths along the edges of the vertebrae, typically large, coarse, fluffy.
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Image Descriptions:
- Enthesitis (Achilles Tendinitis): An image of a leg showing redness and swelling at the Achilles tendon insertion point.
- Dactylitis: Sausage digit: Image of a hand with swollen fingers resembling a sausage.
- Mucocutaneous manifestations: An image of a foot with redness and potential lesions.
- Circinate balanitis: An image of the glans penis showing potential lesions or ulcers with redness.
Rheumatology & Immunology: Active Space
This section covers symptoms, findings, potential causes, and treatments related to Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), two autoimmune diseases.
Central Nervous System (CNS)
-
RA:
- Normal cognitive function: The brain parenchyma is typically unaffected.
- Atlantoaxial subluxation: Instability of the joint between the first and second cervical vertebrae.
- Acute onset quadriparesis: Weakness or paralysis of all four limbs.
- Erosion of the odontoid process: Destruction of the bony projection on the second cervical vertebra.
-
SLE:
- Cognitive decline: Impairment in mental abilities.
Peripheral Nervous System (PNS)
- RA > SLE: Keratoconjunctivitis sicca symptoms: Dryness of the eyes and mouth.
Ocular
-
RA & SLE:
- Episcleritis: Inflammation of the sclera (white part of the eye), the most common ocular manifestation. Not associated with vision loss.
- Scleritis: Inflammation of the deeper layers of the sclera, potentially leading to granulomatous resorption and scleromalacia perforans (causing vision loss).
Vascular
-
Characteristic Symptoms:
- History of smoking: A significant risk factor.
- More common in males.
- Long-standing: Often associated with chronic inflammation.
- Radiodamage: Damage to blood vessels caused by radiation exposure.
- Rheumatoid factor (+) and low complements: Presence of rheumatoid factor and low levels of complement proteins.
- Small vessel > medium vessel muscular arteries in the dermis: Vasculitis primarily affecting smaller blood vessels.
-
Vascular Findings:
- Mesenteric vasculitis: Inflammation of blood vessels in the intestines.
- CNS vasculitis: Inflammation of blood vessels in the brain.
- Mononeuritis multiplex: Inflammation of multiple peripheral nerves.
Hematological
-
Characteristic Symptoms for RA-related conditions:
- Felty's syndrome: A rare complication of rheumatoid arthritis characterized by a triad of rheumatoid arthritis, neutropenia (low neutrophil count), and splenomegaly (enlarged spleen).
- Long-standing: Associated with chronic RA.
- RF positive: Presence of rheumatoid factor.
- HLA DRB104: A particular gene that increases the risk of developing RA.
- Presence of nodules: Rheumatoid nodules are typically seen in patients with Felty's syndrome.
- Deformity: Joint deformities are a feature of RA, and often seen in Felty's syndrome.
- Antibody against citrullinated histones: This antibody is linked to an increased risk of developing diffuse large B-cell lymphoma (DLBCL).
- Increased risk of conversion to DLBCL: There is a higher chance of the development of DLBCL (a type of non-Hodgkin lymphoma) in patients with Felty's syndrome.
- Large granular lymphocytic leukemia: This rare blood cancer can develop in patients with Felty's syndrome.
-
Hematological Findings:
- Anemia of chronic disease: The most common type of anemia seen in patients with RA.
- Warm antibody autoimmune hemolytic anemia: A rare but serious condition causing the destruction of red blood cells.
- Secondary Immune thrombocytopenic purpura (ITP): A disorder causing low platelet counts, leading to excessive bleeding.
- Thrombocytosis: An increased number of platelets in the blood.
Cardiovascular System (CVS)
-
Characteristic Symptoms for CV-related conditions:
- Acute coronary syndrome (ACS): The most common cause of death in patients with RA.
- Pericarditis without tamponade: Inflammation of the pericardium (the sac surrounding the heart), but without fluid buildup.
- Mitral regurgitation: A heart valve defect causing leakage of blood.
Gastrointestinal Tract (GIT)
- Findings: Vasculitis (rare): Inflammation of blood vessels in the gastrointestinal tract.
Endocrine System
-
Findings:
- Osteoporosis: Bone weakening due to chronic inflammation.
- Hypoandrogenism: Low testosterone levels.
Skin
-
Findings:
- Rheumatoid nodule: A firm, painless lump under the skin.
- Pyoderma gangrenosum: A painful skin ulcer.
Additional Findings
- Leukopenia
- Libman-Sacks endocarditis: Inflammation of the heart valves.
- Autoimmune hepatitis:: Inflammation of the liver.
- Vasculitis: Inflammation of blood vessels.
Rheumatoid Arthritis (RA): Lung
- Large granular lymphocytes: Common in male smokers.
-
Pleuritis and pleural effusion (most common): Inflammation of the pleura (lining of the lungs) with fluid buildup.
- pH < 7.2
- Fluid is exudative
- Glucose < 30 g/dL
- Protein > 4 g/dL
- High LDH
-
Interstitial lung disease (ILD): A range of disorders causing inflammation and scarring of the lungs; Usual interstitial pneumonia (UIP) is the most common type.
- Involves the lower lobes
- Idiopathic pulmonary fibrosis: A condition where the lungs become progressively scarred.
- Destruction of lung parenchyma with honeycombing: Characteristic patterns of scarring.
- Dry cough, dyspnea, decreased diffusing capacity of the lung for carbon monoxide (DLCO): Common symptoms.
- Caplan syndrome: A rare association of rheumatoid arthritis, synovitis, IgA rheumatoid factor, and cavitating nodules in the lung.
Rheumatoid Arthritis (RA): Kidney
- Relative sparing: Of amyloid deposition (AA) in the kidney.
- Membranous nephropathy: A condition affecting the filtering units in the kidneys.
Spondyloarthritis: Image Description
- The images include several X-rays and diagrams of the spine, likely used to diagnose and treat SpA, showing spinal abnormalities (spinal fractures, ankylosis, syndesmophytes).
- Diagrams of the spine illustrate anatomical landmarks, like the posterior superior iliac spine (PSIS).
- Descriptions and measurements are present, facilitating clinical interpretation of the images.
Spondyloarthritis: Diagnosis Signs
- Dagger sign: Calcification of the interspinous ligament.
- Trolley track sign: Calcification of the joint capsule.
- Romanus sign: Erosion of the corner of a vertebra.
- Shiny corner sign: Sclerosis (hardening) of a vertebra.
- Square wave vertebra: Vertebrae become square-shaped.
Spondyloarthritis: Modified Schober Test
- Landmark: The posterior superior iliac spine (PSIS).
- Measurement: Distance between two marked points (A to B) is 15 cm. (10 cm above PSIS, 5 cm below PSIS).
- Forward bending: Distance between A to B is measured while the patient bends forward with knees fully extended.
- Normal: A to B distance should increase to at least 20 cm. Less than 20 cm is considered abnormal.
Spondyloarthritis: Treatment
-
Non-radiological axial SpA:
- NSAIDS: Nonsteroidal anti-inflammatory drugs are used as needed for pain relief.
- Exercise and Physiotherapy: Considered essential aspects of management.
- NSAIDS: Specific NSAIDs like Indomethacin (50 mg TID) or Naproxen and Ibuprofen are commonly used.
- Disease prevention: Treatment aims to slow down the progression of the disease.
- Treatment duration: Typically 2-3 weeks.
Rheumatology and Immunology: Important Note
- The information presented is for educational purposes only and should not be interpreted as medical advice.
- Consult a healthcare professional for any health concerns.
Rheumatoid Arthritis: Lung
- Upper Lobe ILD: Can be associated with sarcoidosis, ankylosing spondylitis.
- Osteoporosis: More common in RA, followed by AS, then sarcoidosis, and finally SLE.
Rheumatology and Immunology: Investigation
- MRI - STIR Sequence: STIR (short tau inversion recovery) is a type of MRI sequence.
- Hyperintensity: A bright signal on STIR sequence, but not always conclusive.
Rheumatology and Immunology: X-Ray Grades
| Grade | Description |
|---|---|
| 0 | Normal joints |
| 1 | Slight blurring of cortical margins of the lower 1/3rd of each joint. Earliest X-ray sign |
| 2 | Blurring + Sclerosis |
| 3 | Loss of margins. Widening of joint space |
| 4 | Joint ankylosis |
Rheumatology and Immunology: Other Findings
- 8/1 sacroiliitis (grade 2/3): Inflammation of the SI joint, with significant evidence of joint involvement.
- Bamboo spine: Characteristic X-ray appearance of fused vertebral bodies.
Rheumatology and Immunology: Images
- The document contains radiographic images (MRI and X-ray), likely demonstrating different views of the musculoskeletal system.
- The images potentially show various stages of inflammation and/or damage, such as blurring, loss of cortical margins, widening of the joint space, ankylosis, and bamboo spine formation.
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
- Elderly male: Primarily affects older men.
- Non-inflammatory: A non-inflammatory condition.
- Part of metabolic syndrome: Often associated with metabolic syndrome.
- Ligamentous calcification: Calcification of ligaments in the spinal column.
- Flowing wax appearance in X-ray: Characteristic radiographic appearance.
Peripheral Spondyloarthritis
Reactive Arthritis (ReA)
- Previously known as Reiter's syndrome: A condition characterized by urethritis, arthritis, and conjunctivitis.
- Common extra-articular manifestation: 4A uveitis.
- Male > Female: More common in males.
- Age: Primarily affects adults between 20 and 40 years old.
Infection: Reactive Arthritis
Genitourinary
- Chlamydia trachomatis: The most common cause worldwide.
- Male to Female: Ratio is 9:1 (more common in men).
Gastrointestinal
- Shigella flexneri: The most common cause in India.
- Male to Female: Ratio is 1:1 (similarly common in men and women).
- Salmonella & Campylobacter: Other potential causes, but less common.
Note:
-
- E.coli* and Nisseria are not known to cause reactive arthritis.
Reactive Arthritis: Arthritis Timeline
| Type | Duration | % |
|---|---|---|
| Peripheral | 2–4 weeks | |
| Axial | 30% | |
| Chronic | 20% |
Management of Rheumatoid Arthritis (RA)
- Newly Diagnosed RA: The aim is to achieve remission or low disease activity within 3 months of treatment.
Conventional Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
| Drug | Mechanism of Action |
|---|---|
| Methotrexate (MTX) | Dihydroorotate dehydrogenase inhibitor (Pyrimidine pathway blocker) |
| Leflunomide | Inhibits dihydroorotate dehydrogenase |
| Sulfasalazine | Block synthesis of folic acid |
| Hydroxychloroquine (HCQ) | Toll like receptor inhibitor |
Biological Agents
- Routes: Intravenous (IV) and Subcutaneous (SC)
| Drug | Mechanism of Action |
|---|---|
| Anti TNF-α | Lowers TNF-α levels |
| Infliximab | |
| Etanercept | Fusion molecule; least side effect |
| Certolizumab |
Other Biological Agents:
| Drug | Mechanism of Action | Availability (India) |
|---|---|---|
| Anti CD20 | Rituximab | Available |
| Anti IL-1 | Anakinra | Unavailable |
| Anti IL-6 | Tocilizumab | Available |
| Fusion CTLA-4-FcIgG | Abatacept | Available |
Small Molecules
| Drug | Mechanism of Action |
|---|---|
| JAK Inhibitors | Block JAK enzymes |
| Tofacitinib | 1/3 inhibitor |
| Baricitinib | 1/2 inhibitor |
- Note:* Anakinra is not available in India.
Lower Limb Deformities
- Hammer Toe: A deformed toe, where the middle joint is bent upwards, giving a hammer-like appearance.
- Hallux Valgus: A bunion where the big toe is angled toward the other toes (deviated laterally).
- Pes Planus: Flat feet, where the arch of the foot is flattened.
- Ankle Valgus: A condition where the ankle deviates inward, giving the appearance of a knock-knee.
- Forefoot Varus: A condition where the forefoot points inwards.
Rheumatoid Nodules
- The most common extra-articular manifestation of rheumatoid arthritis (40%).
- Typically painless.
- Found in pressure areas like the elbow and fingers.
- Have a firm to hard consistency.
- Are granulomatous and caused by Type IV hypersensitivity.
- Tend to decrease in size with effective treatment.
- Absent in Juvenile Idiopathic Arthritis (JIA).
- Their presence is associated with a worse prognosis, particularly when accompanied by a positive rheumatoid factor (RF) and high disease activity.
- Methotrexate, a common treatment for rheumatoid arthritis, can actually increase the size of rheumatoid nodules in approximately 10% of patients.
Other Rheumatoid Arthritis Extra-Articular Manifestations
- Synovial Rupture: Can cause calf pain and swelling.
- Bluish Discoloration: May be due to a ruptured Baker's cyst. It is important to differentiate this from a deep vein thrombosis (DVT).
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Test your knowledge on the treatments and complications associated with rheumatoid arthritis and spondyloarthritis. This quiz covers everything from medication management to clinical features and diagnostic criteria. Perfect for medical students or healthcare professionals looking to refresh their knowledge.
