Rheumatology for MRCP Part 1

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most likely diagnosis?

1. Systemic lupus erythematosus A non-erosive arthritis with multisystem features and a positive ANA. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP suggests it.
2. Osteoarthritis Mechanical joint pain worse with use and brief stiffness. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP separates it.
3. Polymyalgia rheumatica Proximal girdle pain and stiffness in an older patient. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it a mimic.
4. Psoriatic arthritis Inflammatory arthritis with psoriasis, dactylitis and nail change. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP raises it.
5. Rheumatoid arthritis correct Correct. A symmetrical small-joint synovitis with prolonged early-morning stiffness and a strongly positive anti-CCP antibody is rheumatoid arthritis.

The point: Rheumatoid arthritis is a chronic symmetrical inflammatory polyarthritis that typically affects the small joints of the hands and feet, causing early-morning stiffness lasting over an hour and, if untreated, joint erosion and deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific serological marker and, with rheumatoid factor, predicts more erosive disease; inflammatory markers are usually raised and x-rays may show juxta-articular osteopenia and erosions. Extra-articular features include rheumatoid nodules, interstitial lung disease, pericarditis, scleritis and episcleritis, Felty syndrome (splenomegaly and neutropenia) and an increased cardiovascular risk. The principle of management is to start a conventional disease-modifying drug early, methotrexate first-line (with folic acid), and to treat to a target of remission or low disease activity, escalating to biologic or targeted synthetic drugs such as TNF inhibitors when the target is not met. Methotrexate is teratogenic and must be stopped before conception, and it requires monitoring of the full blood count and liver function because of the risks of myelosuppression and hepatotoxicity, as well as the rare pneumonitis. Short courses of corticosteroid bridge symptoms while a disease-modifying drug takes effect.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most appropriate investigation?

1. Rheumatoid factor Supports the diagnosis and predicts a worse prognosis. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it useful.
2. Anti-cyclic citrullinated peptide antibody correct Correct. The anti-CCP antibody is the most specific serological test for rheumatoid arthritis and predicts more erosive disease.
3. Inflammatory markers (ESR and CRP) Gauge disease activity. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes them routine.
4. Radiographs of the hands and feet Show erosions and juxta-articular osteopenia. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes them baseline.
5. Ultrasound of the affected joints Detects synovitis and subclinical disease. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it sensitive.

The point: Rheumatoid arthritis is a chronic symmetrical inflammatory polyarthritis that typically affects the small joints of the hands and feet, causing early-morning stiffness lasting over an hour and, if untreated, joint erosion and deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific serological marker and, with rheumatoid factor, predicts more erosive disease; inflammatory markers are usually raised and x-rays may show juxta-articular osteopenia and erosions. Extra-articular features include rheumatoid nodules, interstitial lung disease, pericarditis, scleritis and episcleritis, Felty syndrome (splenomegaly and neutropenia) and an increased cardiovascular risk. The principle of management is to start a conventional disease-modifying drug early, methotrexate first-line (with folic acid), and to treat to a target of remission or low disease activity, escalating to biologic or targeted synthetic drugs such as TNF inhibitors when the target is not met. Methotrexate is teratogenic and must be stopped before conception, and it requires monitoring of the full blood count and liver function because of the risks of myelosuppression and hepatotoxicity, as well as the rare pneumonitis. Short courses of corticosteroid bridge symptoms while a disease-modifying drug takes effect.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college

A 44-year-old woman has 4 months of pain and swelling in the small joints of both hands and wrists, with early-morning stiffness lasting two hours that eases through the day. The metacarpophalangeal joints are boggy and tender. Anti-cyclic citrullinated peptide antibody is strongly positive and CRP is raised. What is the most appropriate management?

1. Methotrexate with folic acid as first-line disease-modifying therapy correct Correct. Methotrexate is the first-line conventional disease-modifying drug, started early with folic acid to prevent joint damage.
2. Monitoring of full blood count and liver function For methotrexate myelosuppression and hepatotoxicity. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it a safety step.
3. A short course of corticosteroid to bridge symptoms Controls symptoms while the disease-modifying drug takes effect. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it a bridge.
4. Escalation to a TNF inhibitor if the target is not met Biologic therapy for inadequate response. A symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP makes it the escalation.
5. Treat-to-target review of disease activity Management follows a treat-to-target strategy, escalating therapy until remission or low disease activity is reached, and a symmetrical small-joint synovitis with prolonged morning stiffness and a positive anti-CCP here points elsewhere.

The point: Rheumatoid arthritis is a chronic symmetrical inflammatory polyarthritis that typically affects the small joints of the hands and feet, causing early-morning stiffness lasting over an hour and, if untreated, joint erosion and deformity. Anti-cyclic citrullinated peptide (anti-CCP) antibody is the most specific serological marker and, with rheumatoid factor, predicts more erosive disease; inflammatory markers are usually raised and x-rays may show juxta-articular osteopenia and erosions. Extra-articular features include rheumatoid nodules, interstitial lung disease, pericarditis, scleritis and episcleritis, Felty syndrome (splenomegaly and neutropenia) and an increased cardiovascular risk. The principle of management is to start a conventional disease-modifying drug early, methotrexate first-line (with folic acid), and to treat to a target of remission or low disease activity, escalating to biologic or targeted synthetic drugs such as TNF inhibitors when the target is not met. Methotrexate is teratogenic and must be stopped before conception, and it requires monitoring of the full blood count and liver function because of the risks of myelosuppression and hepatotoxicity, as well as the rare pneumonitis. Short courses of corticosteroid bridge symptoms while a disease-modifying drug takes effect.

Source: British Society for Rheumatology — management of rheumatoid arthritis British Society for Rheumatology · tier 2, specialty society or college