rheumatoid arthritis 2015-6-9

8/19/2019 Rheumatoid Arthritis 2015-6-9

1/22

Rheumatoid Arthritis: In and Out of the Joint

Mythili Seetharaman, MD | June 9, 2015

• Facebook

• Twitter

• Google+

• LinkedIn

• Eail

• !ancel

•21 o" 2#

• !ontributor In"oration

• |

• $e"erence%

• |

• Feedback

!lo%e

&wi'e to ad(ance


2/22

$)euatoid art)riti% *$ i% a c)ronic in"laator- di%order o" t)e %all .oint% o" t)e )and% and

"eet, in w)ic) %-no(ial in"laation lead% to .oint ero%ion and de"orit-/ It i% an autoiunecondition t)at, be%ide% a""ecting .oint%, al%o )a% %-%teic etraarticular ani"e%tation%/ $ i%

ore coon in woen older t)an 0 -ear%/ It i% an inde'endent ri%k "actor "or cardio(a%cular

di%ea%e/314

Iage courte%- o" Guniita | riana | 6rea%tie/


3/22

T)e %lide %)ow% a 'atient wit) $ a""ecting t)e )and%/ 7)ic) o" t)e )and .oint% are u%uall-

%'ared in $8

/ 7ri%t .oint%

/ :etacar'o')alangeal *:!; .oint%

!/ ;roial inter')alangeal *;I; .oint%

6/ 6i%tal inter')alangeal *6I; .oint%

Iage courte%- o" :-t)ili &eet)araan, :6/


4/22

n%wer< 6/ 6i%tal inter')alangeal *6I; .oint%/

T-'icall-, $ in(ol(e% t)e wri%t%, t)e :!; .oint%, and t)e ;I; .oint% w)ile %'aring t)e 6I;

.oint%/ In contra%t, o%teoart)riti% a""ect% t)e ;I; and 6I; .oint%/ $ al%o %'are% t)e %'ine, ece't

"or t)e cer(ical %'ine/ ll o" t)e large 'eri')eral .oint% can be in(ol(ed in $/

Iage courte%- o" :-t)ili &eet)araan, :6/


5/22

T)e %lide %)ow% a 'atient wit) %ubcutaneou% nodule%/ 7)at i% t)e di""erential diagno%i% "or %uc)

nodule%8

Iage courte%- o" L rent, :6/


6/22

T)e di""erential diagno%i% "or %ubcutaneou% nodule% include% t)e "ollowing324<

• $)euatoid nodule

• Gout- to')u%

• Tendon ant)oa

• :alignanc-

• Fibroa

• &ubcutaneou% granuloa annulare

• :eta%tatic le%ion%

T)e 'atient %)own in t)e %lide )a% r)euatoid nodule%/



7/22

$)euatoid nodule% are aong t)e etraarticular ani"e%tation% o" $= t)e- occur in

%ero'o%iti(e $ and 'ortend ore %e(ere $/ T)e%e nodule% are %ubcutaneou%, "ir, nontender,and obile/ lt)oug) t)e- u%uall- 're%ent on eten%or %ur"ace% o" t)e elbow%, "inger%, or

"orear%, t)e- can al%o occur in internal organ% *eg, lung% or lar-n/ :et)otreate t)era'- can

%oetie% cau%e an increa%e in r)euatoid nodule%/

Iage courte%- o" :ed%ca'e/


8/22

T)e %lide %)ow% a radiogra') o" t)e rig)t )and o" a >1-earold woan wit) $/ 7)at are t)e

ain "eature% o" $ on radiogra')-8



9/22

$adiogra')ic "eature% o" $ include t)e "ollowing<

• ;eriarticular o%teo'enia

• :arginal ero%ion%

• Joint%'ace narrowing

• Joint de%truction wit) de"oritie%

• &ubluation

• on- ank-lo%e%



10/22

In 2010, t)e erican !ollege o" $)euatolog- *!$ and t)e Euro'ean League gain%t

$)euati% *E?L$ 'ubli%)ed criteria "or $ diagno%i% *%)own/3#4 T)e diagno%i% i%deterined on t)e ba%i% o" a %coreba%ed algorit)/ T)e %core% "or "our indi(idual "actor% *.oint

in(ol(eent, %erolog-, acute')a%e reactant%, and %-'to duration are added= t)e aiu

'o%%ible total %core i% 10/ For a de"inite diagno%i% o" $, a total %core o" @ or )ig)er i% reAuired/!; B antiCcitrullinated 'rotein antibod-= !$; B !reacti(e 'rotein= E&$ B er-t)roc-te

%edientation rate= $F B r)euatoid "actor/

da'ted "ro leta)a 6 et al/3#4


11/22

55-earold woan wit) $ o" 2 -ear%D duration )a% acti(e %-no(iti% de%'ite treatent wit)

)-dro-c)loroAuine, %ul"a%alaine, and 'redni%one/ er 'uri"ied 'rotein deri(ati(e *;;6tuberculin te%t re%ult i% 'o%iti(e, wit) 1 induration/

7)ic) o" t)e "ollowing $ edication% u%t be u%ed wit) caution in t)i% 'atient8

/ :et)otreate

/ -dro-c)loroAuine

!/ In"liiab

6/ &ul"a%alaine

Iage courte%- o" lila0> | 6rea%tie/


12/22

n%wer< !/ In"liiab/

Tuor necro%i% "actor *TF antagoni%t% and ot)er biologic di%ea%eodi"-ing antir)euatic

drug% *6:$6% u%ed to treat $ are a%%ociated wit) an increa%ed ri%k o" tuberculo%i% *T

reacti(ation/ ccordingl-, be"ore initiation o" biologic t)era'-, all 'atient% %)ould be routinel-%creened "or latent T wit) ;;6 te%ting *%)own or inter"eron gaa relea%e a%%a- and c)e%t

radiogra')-/ ;atient% wit) latent T %)ould be treated "or at lea%t @ ont)% be"ore biologict)era'- i% %tarted/

Iage courte%- o" !enter% "or 6i%ea%e !ontrol and ;re(ention/


13/22

5-earold woan w)o )a% long%tanding %ero'o%iti(e $ wit) nodule% 're%ent% wit) 'ain and

di%coloration in one o" )er little "inger%/

7)ic) o" t)e "ollowing i% t)e o%t likel- diagno%i%8

/ $)euatic "e(er

/ In"ecti(e endocarditi%

!/ ntiC')o%')oli'id antibod- %-ndroe

6/ $)euatoid (a%culiti%



14/22

n%wer< 6/ $)euatoid (a%culiti%/

$)euatoid (a%culiti% i% a rare ani"e%tation o" $/34 &all(e%%el (a%culiti% u%uall- in(ol(e%

t)e %kin= large(e%%el (a%culiti% can iic 'ol-arteriti% nodo%a/ io'%- o" t)e %kin %)ow%

leuckoc-tocla%tic (a%culiti%/ er(e bio'%- a- be needed "or ner(e in(ol(eent, and abdoinalangiogra')- a- be reAuired i" an internal organ i% in(ol(ed/ Treatent i% ba%ed on t)e %e(erit-

o" t)e illne%%/ ?nderl-ing $ %)ould be well controlled/



15/22

>0-earold an wit) wellcontrolled $ *on a regien o" et)otreate weekl-, %ubcutaneou%

adaliubab e(er- 2 week%, and 'redni%one 5 gda- 're%ent% wit) a 'ain"ul, %wollen rig)t knee .oint, w)ic) )e )a% )ad "or t)e 'a%t # da-%/ T)ere i% no )i%tor- o" traua, "e(er, or 'ain in an-

ot)er .oint%/ Eaination re(eal% a oderate%ied rig)t knee e""u%ion wit) wart), tenderne%%,

and liited range o" otion/ T)e 'atientD% )and% %)owed c)ronic %-no(iti% in t)e wri%t%, t)e :!; .oint%, and t)e ;I; .oint%/

7)ic) o" t)e "ollowing i% t)e o%t a''ro'riate net %te' in anageent8

/ Initiation o" cortico%teroid% "or 'o%%ible $ "lare

/ :agnetic re%onance iaging *:$I o" t)e rig)t knee

!/ Joint a%'iration and "luid anal-%i%

6/ Intraarticular in.ection o" cortico%teroid%

E/ L-e titer

Iage courte%- o" &cience ;)oto Librar-/


16/22

n%wer< !/ Joint a%'iration and "luid anal-%i%/

In"ection %)ould alwa-% be %u%'ected in an- onoart)riti%, e(en again%t a background o" $,

'articularl- in 'atient% recei(ing iuno%u''re%%i(e t)era'-/ b%ence o" "e(er doe% not eclude

in"ection/ It i% i'ortant to %tart e'iric antibiotic t)era'- "or %e'tic art)riti% w)ile awaitingculture re%ult%/ Staphylococcus aureus i% t)e organi% t)at o%t coonl- cau%e% %e'tic

art)riti%/ $ "lare can be con%idered a% t)e etiolog- once in"ection )a% been clearl- ruled out/

Iage courte%- o" :ed%ca'e/


17/22

55-earold woan 're%ent% wit) a 2da- )i%tor- o" redne%% and di%co"ort in t)e le"t e-e/

T)ere )a% been no c)ange in )er (i%ion, and %)e denie% )a(ing an- ')oto')obia/ La%t -ear, t)e 'atient )ad one %iilar e'i%ode in t)e %ae e-e/ &)e co'lain% o" e'eriencing 'ain in )er )and%

wit) ar %ti""ne%% "or t)e 'a%t ont) and )a% ade an a''ointent to be e(aluated/

7)at i% t)e diagno%i%8



18/22

T)e diagno%i% i% e'i%cleriti%, a condition c)aracteried b- redne%%, engorged e'i%cleral (e%%el%,

ab%ence o" tenderne%%, and noral (i%ion/ $ecurrent e'i%ode% a- be noted/ E'i%cleriti% can bea%%ociated wit) %-%teic di%ea%e% %uc) a% $ and lu'u%= ot)er ani"e%tation% include dr- e-e%

and %cleriti%/ E'i%cleriti% re%'ond% to treatent wit) to'ical lubricant%, non%teroidal anti

in"laator- drug% *&I6%, and %teroid%/



19/22

$ can a""ect t)e lung% in (ariou% wa-%,354 including t)e "ollowing<

• Eudati(e 'leural e""u%ion

• Inter%titial lung di%ea%e ?%ual inter%titial 'neuonia= non%'eci"ic inter%titial 'neuonia

*%)own

• $)euatoid nodule%

• ;ulonar- )-'erten%ion

• ronc)ioliti% obliteran%

• 6rugrelated lung di%ea%e

• In"ection

Iage courte%- o" G :urali, :6/


20/22

In anaging r)euatoid lung di%ea%e, t)e "ollowing ke- 'oint% %)ould be ke't in ind<

• $)euatoid nodule% occur ore coonl- in en, and alignanc- u%t be ecluded

• 7it) r)euatoid 'leural e""u%ion%, gluco%e le(el% in t)e 'leural "luid are low becau%e o" a

gluco%e tran%'orter de"ect

• &oker% wit) $ de(elo' inter%titial lung di%ea%e *IL6 a% a con%eAuence o"

citrullination o" 'rotein% in t)e lung%

• ;ulonar- )-'erten%ion in $ i% rare

• :et)otreateinduced lung di%ea%e i% a diagno%i% o" eclu%ion

• In"ectionHin 'articular, -cobacterial di%ea%eHu%t be ruled out in $ 'atient% w)o)a(e been treated wit) TF in)ibitor% and ot)er biologic agent%


21/22

7it) regard to anageent o" $ in 'regnanc-, w)ic) o" t)e "ollowing %tateent% i% correct8

/ :et)otreate i% contraindicated

/ In"liiab i% teratogenic

!/ Le"lunoide i% %a"e in 'regnanc-

6/ $ "lare% during 'regnanc- and i'ro(e% a"ter deli(er-

Iage courte%- o" ;etro | :elodi.a | 6rea%tie/


22/22

n%wer< / :et)otreate i% contraindicated/

:et)otreate and le"lunoide are cla%%i"ied a% categor- agent% and t)u% %)ould not be u%ed

during 'regnanc-/ TF in)ibitor% *eg, in"liiab, etanerce't, and adaliuab and calcineurin

in)ibitor% *eg, tacroliu% and c-clo%'orine a- be continued during 'regnanc-/ batace't,rituiab, and -co')enolate u%t be wit)drawn be"ore 'regnanc-/ ?%uall-, $ i'ro(e%

during 'regnanc- and "lare% a"ter deli(er-/

Iage courte%- o" 7eb:6/

http://reference.medscape.com/features/slideshow/rheumatoid-arthritis#page=21

rheumatoid arthritis 2015-6-9

Documents