Rheumatology
Immune-mediated disorders of the musculoskeletal system and soft tissues
Can have a genetic component
Tend to be autoimmune – causing inflammatory joint pain
Treated commonly by immunosuppressants
Inflammatory joint pain:
- Morning stiffness over an hour
- Swelling/redness
- More stiffness than pain
- Better with movement
- ESR and CRP elevated
Non-inflammatory joint pain:
- Morning stiffness less than an hour
- Less swelling
- More pain than stiffness
- Worse with movement
Autoimmune Antibodies
ANA – non-specific marker for autoimmune disease
All patients with lupus will be positive for ANA but a lot of other illnesses can also
lead to positives
Rheumatoid factor – non-specific marker for autoimmune disease
Some patients with rheumatoid arthritis will be positive along with other illnesses
Not all RA patients will be RF positive
- SCL70: specific for scleroderma
- Centromere: specific for limited cutaneous scleroderma
- Anti dsDNA: specific for SLE
- Anti CCP: specific for RA
- RoSSA/LaSSB: specific for Sjogrens
- SLAB27: Ankylosing spondylitis, Reiter syndrome, IBD
Rheumatologic Medications
Immunosuppressants are given to suppress immune system
This results in increased risk of infection
- Disease modifying anti rheumatic drugs (DMARDs)
Inhibit T-cells and B-cells
*Methotrexate: must be monitored, can be hepatotoxic and teratogenic
*Hydroxychloroquine (SLE): can cause retinal toxicity
- Biologics (monoclonal antibodies -mab/-cept)
More targeted than DMARDs – directly target B-cells or ILs or TNFs
Can be injected/IV – very expensive
Rheumatoid Arthritis
Definition Systemic, inflammatory joint disorder
- Predominantly in peripheral joints (hands and feet)
, Epidemiology Presents at any age – usually 20-30s
- More predominant in females
Aetiology
Risk factors
Symptoms - Symmetrical joint pain
- Stiffness
- Soft tissue swelling
- Functional loss (especially in hands)
- Can result in deformities of fingers
Systemic SSx:
- Weight loss, fever, malaise 6+ weeks
- Skin ulcers
- Heart – pericarditis/conduction defects
- Palmar erythema, rashes
- Pleural effusions/lung nodules
- Scleritis of eye
- Nerve entrapment
Rheumatoid arthritis Osteoarthritis
- Inflammatory - Non-inflammatory
- Worse in the morning - Better in the mornings
- Better as day goes on - Worse as day goes on
- Morning stiffness more - Morning stiffness less
than 1 hour than 15m
- Symmetrical - Non-symmetrical
- Any age - Increases with age
- Small joints affected - Large joints affected
more more (knee, hips)
- Erosions found on XR - XR: narrowing of joint
- CCP+ space, osteophytes,
subchondral sclerosis
- No swelling or redness
Signs
Investigations - FBC
- ESR and CRP (elevated)
- Anti-cyclic citrullinated peptide antibody (anti CCP) = most
specific test
- Rheumatoid factor = false positives (other conditions) and
false negatives (early on)
- ANA titre can be positive in some patients
Immune-mediated disorders of the musculoskeletal system and soft tissues
Can have a genetic component
Tend to be autoimmune – causing inflammatory joint pain
Treated commonly by immunosuppressants
Inflammatory joint pain:
- Morning stiffness over an hour
- Swelling/redness
- More stiffness than pain
- Better with movement
- ESR and CRP elevated
Non-inflammatory joint pain:
- Morning stiffness less than an hour
- Less swelling
- More pain than stiffness
- Worse with movement
Autoimmune Antibodies
ANA – non-specific marker for autoimmune disease
All patients with lupus will be positive for ANA but a lot of other illnesses can also
lead to positives
Rheumatoid factor – non-specific marker for autoimmune disease
Some patients with rheumatoid arthritis will be positive along with other illnesses
Not all RA patients will be RF positive
- SCL70: specific for scleroderma
- Centromere: specific for limited cutaneous scleroderma
- Anti dsDNA: specific for SLE
- Anti CCP: specific for RA
- RoSSA/LaSSB: specific for Sjogrens
- SLAB27: Ankylosing spondylitis, Reiter syndrome, IBD
Rheumatologic Medications
Immunosuppressants are given to suppress immune system
This results in increased risk of infection
- Disease modifying anti rheumatic drugs (DMARDs)
Inhibit T-cells and B-cells
*Methotrexate: must be monitored, can be hepatotoxic and teratogenic
*Hydroxychloroquine (SLE): can cause retinal toxicity
- Biologics (monoclonal antibodies -mab/-cept)
More targeted than DMARDs – directly target B-cells or ILs or TNFs
Can be injected/IV – very expensive
Rheumatoid Arthritis
Definition Systemic, inflammatory joint disorder
- Predominantly in peripheral joints (hands and feet)
, Epidemiology Presents at any age – usually 20-30s
- More predominant in females
Aetiology
Risk factors
Symptoms - Symmetrical joint pain
- Stiffness
- Soft tissue swelling
- Functional loss (especially in hands)
- Can result in deformities of fingers
Systemic SSx:
- Weight loss, fever, malaise 6+ weeks
- Skin ulcers
- Heart – pericarditis/conduction defects
- Palmar erythema, rashes
- Pleural effusions/lung nodules
- Scleritis of eye
- Nerve entrapment
Rheumatoid arthritis Osteoarthritis
- Inflammatory - Non-inflammatory
- Worse in the morning - Better in the mornings
- Better as day goes on - Worse as day goes on
- Morning stiffness more - Morning stiffness less
than 1 hour than 15m
- Symmetrical - Non-symmetrical
- Any age - Increases with age
- Small joints affected - Large joints affected
more more (knee, hips)
- Erosions found on XR - XR: narrowing of joint
- CCP+ space, osteophytes,
subchondral sclerosis
- No swelling or redness
Signs
Investigations - FBC
- ESR and CRP (elevated)
- Anti-cyclic citrullinated peptide antibody (anti CCP) = most
specific test
- Rheumatoid factor = false positives (other conditions) and
false negatives (early on)
- ANA titre can be positive in some patients
