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Rheumatoid arthritis

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Rheumatoid arthritis

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USMLE® Step 1 style questions USMLE

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A 53-year-old woman comes to the emergency department because of abdominal pain and distention. The patient has had several episodes of emesis prior to arrival. Past medical history is notable for rheumatoid arthritis and gallstones treated with laparoscopic cholecystectomy. Temperature is 37.6°C (99.7°F), pulse is 96/min and blood pressure is 140/83 mmHg. Physical examination reveals diffuse tenderness to palpation of the abdomen and high-pitched bowel sounds on auscultation. Laboratory testing reveals the following findings:

 
 Laboratory value  Result 
 Sodium  145 mmol/L 
 Potassium  3.7 mmol/L 
 Chloride  102 mmol/L 
 Bicarbonate  30 mmol/L 

Imaging reveals obstruction of the small intestine. The patient is taken to the operating room, undergoes endotracheal intubation, and surgical adhesiolysis is performed. Three hours later, neurological examination reveals areflexia and impaired sensation in all extremities. Which of the following is the most likely explanation for the neurological defects?  

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Amyloidosis

with rheumatoid arthritis p. 472

Anemia of chronic disease p. 427

rheumatoid arthritis p. 472

Carpal tunnel syndrome p. 450

rheumatoid arthritis p. 472

Glucocorticoids

rheumatoid arthritis p. 472

Hydroxychloroquine

rheumatoid arthritis p. 472

Methotrexate p. 443

rheumatoid arthritis p. 472

Neutropenia

rheumatoid arthritis p. 472

Nonsteroidal anti-inflammatory drugs (NSAIDs) p. 495

rheumatoid arthritis p. 472

Obesity

osteoarthritis/rheumatoid arthritis p. 472

Pericarditis

rheumatoid arthritis p. 472

Rheumatoid arthritis p. 472

anemia of chronic disease and p. 427

autoantibody p. 113

azathioprine for p. 444

biliary cirrhosis p. 402

carpal tunnel syndrome and p. 452

celecoxib for p. 495

etanercept for p. 497

HLA-DR4 and p. 98

immunosuppressants p. 118

infliximab/adalimumab for p. 497

labs/findings p. 728

leflunomide for p. 495

methotrexate for p. 444

rituximab for p. 120, 446

uveitis p. 551

Sjögren syndrome p. 474

rheumatoid arthritis p. 472

Splenomegaly

rheumatoid arthritis p. 472

Transcript

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In rheumatoid arthritis, “arthr-“ refers to joints, “-itis” means inflammation, and “rheumatoid” comes from rheumatism, which more broadly refers to a musculoskeletal illness.

So, rheumatoid arthritis is a chronic, inflammatory disorder that mostly affects the joints, but can also involve other organ systems like the skin and lungs as well.

Alright, so a healthy joint typically has two bones covered with articular cartilage at the ends.

Articular cartilage is a type of connective tissue that acts like a protective cushion - a lubricated surface for bones to smoothly glide against.

One type of joint, like the knee joint is called a synovial joint.

A synovial joint connects two bones with a fibrous joint capsule that is continuous with the periosteum or outer layer of both bones.

The fibrous capsule is lined with a synovial membrane that has cells that produce synovial fluid and remove debris.

The synovial fluid is normally a viscous fluid like the jelly-like part of a chicken egg and it helps lubricate the joint.

To help serve these synovial cells, the synovial membrane also has blood vessels and lymphatics running through it.

Together, the synovial membrane and the articular cartilage form the inner lining of the joint space.

Rheumatoid arthritis is an autoimmune process that is typically triggered by an interaction between a genetic factor and the environment.

For example, a person with a certain gene for an immune protein like human leukocyte antigen, or HLA- DR1 and HLA–DR4, might develop rheumatoid arthritis after getting exposed to something in the environment like cigarette smoke or a specific pathogen like a bacteria that lives in the intestines.

These environmental factors can cause modification of our own antigens, such as IgG antibodies or other proteins like type II collagen or vimentin.

Τype II collagen and vimentin can get modified through a process called citrullination.

That’s when the amino acid arginine found in these proteins is converted into another amino acid, citrulline.

Meanwhile, due to the susceptibility genes HLA- DR1 and HLA–DR4, immune cells sometimes are not “clever” enough, so they get confused by these changes and they no longer recognize these proteins as self-antigens.

The antigens get picked up by antigen- presenting cells, and get carried to the lymph nodes to activate CD4+ T-helper cells.

Summary

Rheumatoid arthritis (RA) is a systemic inflammatory disorder of autoimmune origin that is primarily characterized by progressive, symmetric joint destruction, especially in the wrists and fingers, but may also affect other joints and many organs, such as the skin, heart, blood vessels, and lungs. Symptoms of RA include fatigue, joint pain, stiffness, and swelling, which can lead to decreased range of motion and joint deformity. RA is a chronic condition and treatment is focused on managing symptoms and preventing further joint damage. Treatment options include medications such as non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs) and biologic agents, physical therapy, and in some cases, surgery.

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