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What is a primary characteristic of the onset of rheumatoid arthritis?
Which joints are typically affected first in rheumatoid arthritis?
Which of the following is a hallmark symptom of rheumatoid arthritis?
Which of the following symptoms is not commonly associated with rheumatoid arthritis?
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What is the male to female ratio typically observed in rheumatoid arthritis?
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What is a common extra-articular manifestation of rheumatoid arthritis?
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Which imaging study is often used to aid in the diagnosis of rheumatoid arthritis?
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Which type of arthritis is characterized by episodic self-limited attacks?
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Which of the following is a late-stage manifestation of rheumatoid arthritis in the hands?
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What is a common joint involvement pattern in late-stage rheumatoid arthritis?
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Which of the following laboratory findings is associated with rheumatoid arthritis?
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Which condition is not a typical extra-articular manifestation of rheumatoid arthritis?
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What is the main purpose of glucocorticoids in the treatment of rheumatoid arthritis?
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Which imaging study is used to assess atlantoaxial subluxation in rheumatoid arthritis?
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Which statement about treatment strategies for rheumatoid arthritis is correct?
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What is the significance of a positive rheumatoid factor in the context of rheumatoid arthritis?
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What is the maximum single weekly dose of Methotrexate for treating rheumatoid arthritis?
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Which of the following is NOT a characteristic toxicity associated with Methotrexate?
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Long-term use of hydroxychloroquine may primarily lead to which serious complication?
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Which drug is indicated for treatment in a patient with elevated blood pressure alongside rheumatoid arthritis?
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Which of the following is a common extraarticular manifestation of rheumatoid arthritis?
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What is the recommended daily dosage range for Sulfasalazine?
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Adult-Onset Still Disease may present with which of the following symptoms?
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Which small-molecule inhibitor is known to have an increased risk of herpes zoster reactivation?
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Study Notes
Introduction
- Rheumatoid Arthritis (RA) is a chronic, systemic autoimmune disease that primarily targets the synovium.
Epidemiology
- Affects 1% of the adult population.
- Can present at any age, but typically affects women in their late childbearing years.
- Female to male ratio is 3:1.
Clinical Findings
- Onset: Can be insidious (weeks to months) or fulminant (abrupt onset).
- Systemic Symptoms: Fatigue, low-grade fevers (≤38°C), weight loss.
- Distribution of Involved Joints: Primarily affects PIP, MCP, and MTP joints. Large joints may be involved later. Spares DIP joints.
- Morning Stiffness: Hallmark of inflammatory arthritis. Worst upon arising or after prolonged rest, lasting for hours. Improves with activity and warmth.
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Articular Manifestations: Pain, swelling, and stiffness.
- Hands: Synovial proliferation leads to swelling of MCP and PIP joints. Late-stage may lead to ulnar deviation, swan neck deformities, and boutonnière deformities.
- Wrists: Early stage synovial proliferation, late stage carpal tunnel syndrome.
- Feet: MTP joint involvement, subluxation of toes, skin ulceration.
- Large Joints: Involvement is common in late stages, commonly symmetrical.
- Cervical Spine: Atlantoaxial subluxation (MRI cervical spine can help diagnose).
Extra-Articular Manifestations
- Rheumatoid nodules.
- Vasculitic leg ulcers.
- Sjogren's syndrome.
- Lung Complications: Interstitial lung disease and Caplan syndrome.
Laboratory Findings
- CBC: Anemia of chronic disease, white blood cell count may be increased, decreased (Felty’s syndrome), or normal. Thrombocytosis can occur in active disease.
- Acute-Phase Reactants: Elevated ESR and CRP.
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Autoantibodies:
- Rheumatoid factor (RF): against IgG.
- Anti-CCP antibodies.
- ANA (30%).
- ANCA (30%).
- Synovial Fluid: 5,000-50,000 WBCs/mcL.
Imaging Studies
- X-ray: Juxtaarticular demineralization, joint-space narrowing. In late stages, bony erosions, deformities, and subluxation may be seen.
- Musculoskeletal Ultrasound: Detects synovitis, erosions, and tenosynovitis.
- MRI Cervical Spine: Used to diagnose atlantoaxial subluxation.
Making the Diagnosis
- No single finding on physical examination or laboratory testing is diagnostic of RA.
Differential Diagnosis
- Many other conditions can mimic RA, including:
- Osteoarthritis
- Gout
- Psoriatic arthritis
- Systemic lupus erythematosus
- Polymyalgia rheumatica
- Infectious arthritis
Treatment
- Window of Opportunity: Aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) early leads to better long-term outcomes.
- Glucocorticoids: Low-dose prednisone is often used, but not appropriate as monotherapy. Intra-articular injections can be helpful for residual activity in large joints.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Provide symptomatic relief but not a sole therapy for RA.
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Synthetic DMARDs:
- Methotrexate: The most effective DMARD, single dose weekly (max 25mg). Folate supplementation required. Monitor blood cell counts, liver function, and creatinine. Toxicities: Oral ulcers, nausea, hepatotoxicity, bone marrow suppression, pneumonitis.
- Hydroxychloroquine: Antimalarial, 200-400 mg daily. Retinal toxicity is a concern.
- Sulfasalazine: 1-3 g daily, hypersensitivity can occur.
- Leflunomide: 10-20 mg, can cause diarrhea, hepatotoxicity, hypertension, and is teratogenic.
- Biologic DMARDs: Used in combination with synthetic DMARDs. Increase risk of infection (tuberculosis, hepatitis B).
- Janus Kinase (JAK) Inhibitors: Small-molecule inhibitors. Oral administration. Increased risk of herpes zoster reactivation. Examples: Tofacitinib, baricitinib, and upadacitinib.
Adult-Onset Still Disease
- Characterized by quotidian fever greater than 39°C.
- Other symptoms include evanescent, salmon-colored macular rash, pharyngitis, polyarthralgia, lymphadenopathy, splenomegaly, and serositis.
- Laboratory abnormalities: Leukocytosis, elevated acute phase reactants (ESR and CRP), and dramatic increases in serum ferritin.
Key Points
- RA is a chronic, systemic autoimmune disease targeting the synovium.
- Early diagnosis and aggressive treatment are vital for better outcomes.
- Synthetic and biologic DMARDs are essential elements of treatment.
- Potential complications include: Joint deformities, extra-articular manifestations, and increased risk of infection.
- Regular monitoring is crucial to assess effectiveness and adjust treatment strategies.
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Description
This quiz explores the critical aspects of Rheumatoid Arthritis (RA), including its epidemiology, clinical findings, and common symptoms. Understand how RA affects the joints and the systemic implications of this autoimmune disease. Test your knowledge about its characteristics and manifestations.
