Rheumatoid Questions andNotes on OA and RA

A patient presents with rheumatoid arthritis. On examination of her hands, she has several joint deformities which are typical of rheumatoid arthritis. The doctor therefore decides to order blood tests. Give TWO blood tests (no abbreviations) that can be used in the diagnosis of rheumatoid arthritis (2 marks).Rheumatoid factor Anti-citrullinated protein antibodies Anti-cyclic citrullunated peptides Anti-mutated citrullinate vimentin assay

Rheumatoid arthritis causes inflammation of the synovial membranes. Describe the histological appearance of a normal synovial joint membrane (2 marks) and the appearance of the synovial membrane in a joint with acute rheumatoid arthritis. (2 marks)Normal: 2 layers, the intima composed of synovial and phagocytic cells (1 mark) (1 mark if lined by synovial cells or phagocytes) and subintima composed of loose connective tissue and blood vessels (1 mark) ACCEPT hyaline cartilage RA: oedematousand inflamed (1 mark) multiplication/proliferation of synovial lining cells forming a pannus (1 mark)

The patient says she is having an endoscopy done. Before this is done, the doctor decides to send her for a cervical spine X-ray. Explain why it is important to perform a cervical spine X-ray in this particular patient. (3 marks) Patient could have RA cervical spine with instability (1 mark) Atlanto – axial /C1 – C2 subluxation could occur during endoscopy (1 mark) (have to mention endoscopy to get full mark and reason for compression) causing compression/damage the spinal cord/nerves (1 mark)

Patients with rheumatoid arthritis can also develop pleural effusions. (i) Describe the pleura of the lungs. (3 marks) (ii) In an upright posture where would the fluid collect? (1 mark) (i) Serous membrane of two continuous layers: a visceral layer (allow outer) adhered to the lung (1 mark) and a parietal layer (allow inner) which lines the inner aspect of the chest wall, the diaphragm, sides of pericardium & mediastinum (1 mark) NB not just chest wall ) Between the layers is the pleural cavity, a potential space which contains a tiny amount of serous fluid (1 mark) (ii) Costodiaphragmatic recess (1 mark) or costophrenic or space angle

List some extra-articular manifestations of rheumatoid arthritisScleritisSjogren’s Syndrome LymphadenopathyPericarditisBursitis/nodulesTendon sheath swellingTenosynovitisAmyloidosisPleural effusionFibrosing alveolitisCarpal tunnel syndrome

Osteoarthritis ("Wear and Tear") Rheumatoid (Autoimmune)Obesity (Risk factor) Occupation (Risk factor) 3:1 Female:Male ratioHeberden’s Nodes Swan neck deformityBouchard’s Nodes Ulnar deviation of the MCP jointCrepitations Mainly small joints effectedBony enlargements Symmetry Osteophytes BilateralSubchodrial cysts Extra-articular manifestationsHigher inidence after menopause Morning stiffness worseStiffness lasts <30mins in the morning Stiffness lasts >30mins in the morningUnilateral Rheumatoid nodulesJoint space narrowing Joint space narrowingAsymmetrical

Increased incidence after menopause

NOTE: These are not all of the comparisons that can be made, or features of RA and OA.Also, wherever you have two diseases that can be compared easily make sure you are able to distinguish differences between the two easily, for example:Type I vs Type II DiabetesUlcerative Colitis vs Crohn’s Another cheeky one to think about is Apoptosis vs Necrosis

Hand signs for Rheumatoid Arthritis

REMEMBER: You need to be able to describe what is happening in each of the signs.

Swan-neck deformity:Flexion of the DIPHyperextension of the PIP joint

Boutonniere deformity:Hyperextension of DIPFlexion of PIP

NOTE: Swan-neck and Boutonniere sign are the opposite of each other.

Ulnar deviation of the MCP joint:The fingers are deviating toward the ulnar bone at the MCP joint

These nodes are seen in Osteoarthritis.

There are several ways to remember which way round these nodes go:

Heberden’s Node:The outer Hebrides are far away, and Heberden’s nodes are the ones furthest away (on the DIP joint) from you.

Bouchard’s Node:The French for mouth is ‘bouche’ and the node closest to the mouth (on the PIP) is called Bouchard’s node.

(These are simple ways of remembering them. Remember you need to know what PIP and DIP stand for)

PIP: Proximal InterPhalangeal JointDIP: Distal InterPhalangeal Joint

The exam questions were taken straight from a past paper, along with the answers, bar the last example.

If you have any questions about anything you have read in this, or noticed any mistakes please contact me.

Amritpal SandhuA.Sandhu@warwick.ac.uk