Rheumatoid arthritis ´ëÀå°æ Á¤¸®
1. RA¿Í °ü°èÀÖ´Â HLA: HLA-DR4
2. RA ¸é¿ªÇÐÀû ±âÀü: delayed type hypersensitivity¿Í À¯»çÇÏ´Ù.
- synovium³» ¸¹Àº ¿°Áõ¼¼Æ÷ÀÇ Ä§À±À» º¼¼ö ÀÖ´Ù.
- T lymphocyte°¡ ÁַΠħÀ±µÇ¾î Àִµ¥, ÁÖ·Î CD4+ T cellÀÌ´Ù.
- ¿°Áõ¼¼Æ÷¿¡¼ ¸¹Àº cytokine°ú lymphokineÀÌ ºÐºñµÇ¾î ±¹¼ÒÀû, Àü½ÅÀû Áõ»óÀÌ ³ªÅ¸³´Ù.
- B cellµµ Áõ°¡Çϴµ¥ ¿©±â¼ »ý»êµÇ´Â polyclonal immunoglobulin°ú RF´Â immune
complex¸¦ Çü¼ºÇÑ´Ù.
3. RAÀÇ target antigenÀº collagen type II, heat shock proteinÀÌ´Ù.
4. RA¿¡¼ tissue-damaging enzyme(collagenase, protease)¸¦ »ý¼ºÀ» ÀÚ±ØÇÏ¿© cartilage,
bone¿¡ ¼Õ»óÀ» ÁÖ´Â cytokine: IL-1, TNF-¥á
5. proinflammatory cytokines: IL-1, TNF-¥á, IL-6, IL-8, GM-CSF
anti-inflammatory cytokines: IL-1 receptor antagonist, soluble TNF receptor, IL-10, TGF-¥â
6. RA Áø´Ü±âÁØ: 7°¡ÁöÁß 4°¡Áö ÀÌ»ó, ¨ç - ¨ê´Â 6ÁÖÀÌ»ó
i) morning stiffness
ii) 3°³ÀÌ»ó arthritis
iii) hand joints arthritis(PIP, MP, or wrist)
iv) symmetric arthritis
v) rheumatoid nodules
vi) RF(+)
vii) X-ray»ó hand or wrist joints¿¡ erosion and/or periarticular osteopenia
7. Rheumatoid factor = IgM (IgG, IgAµµ °üÂûµÈ´Ù)
- screening test·Î´Â Àǹ̰¡ ¾ø´Ù.
- RF(+)À̸é (-)ÀÎ °æ¿ìº¸´Ù ¿¹Èİ¡ ³ª»Ú´Ù.
- rheumatoid noduleÀ̳ª vasculitis°¡ Àִ ȯÀÚ¿¡¼´Â Ç×»ó ¹ß°ßµÈ´Ù.
- RF(+)ÀΠȯÀÚÀÇ 1/3¿¡¼ RA·Î ¹ßÀüÇÑ´Ù.
- Á¤»óÀÎÀÇ 5%¿¡¼ ¹ß°ßµÇ°í ³ªÀ̰¡ µê¿¡µû¶ó Áõ°¡ÇÏ¿© 65¼¼ À̻󿡼´Â 10-20%¿¡¼
¾ç¼ºÀÌ´Ù.
- RF¸¦ ¸¸µå´Â B cellÀº º¸Åë polyclonal expansionÇÑ´Ù.
8. synovial fluid
turbid, fluidÀÇ Á¡µµ¡é
WBC 5-50,000(poly dominant)
glucose¾à°£ °¨¼Ò or Á¤»ó, proteinÁõ°¡
C3, C4¡é
9. high titer RFÀÎ °æ¿ì
i) mononeuritis multiplex
ii) Felty's syndrome
iii) subcutaneous nodule
iv) rheumatoid vasculitis
v) more severe joint disease
10. RAÀÇ articular manifestation
- axial involvement´Â upper cervical spine¿¡ ±¹Çѵǰí, L-spine¿¡´Â ħ¹üµÇÁö ¾Ê´Â´Ù.
- DIP jointħ¹üµµ µå¹°´Ù.
- carpal tunnel syndrome
11. Baker's cyst: synovial inflammationÀÌ popliteal space·Î ÆÛÁ®¼ ¹«¸µÞÂÊ¿¡ pain &
swellingÀ» ¾ß±â, USG & doppler·Î Áø´Ü°¡´É
12. RA¿¡¼ cervical spineÀ» È®ÀÎÇϱâ À§ÇÑ 2°¡Áö view
i) fixed lateral view of cervical spine
ii) C-spine open mouth frontal view
13. RAÀÇ ÀÓ»óÀû Ư¡
- CNS¸¦ ħ¹üÇÏ´Â °æ¿ì´Â µå¹°´Ù.
- pulmonary hypertensionÀº µå¹°´Ù.
- high-grade fever´Â µå¹°´Ù.
- subcutaneous noduleÀº 20-30%¿¡¼ ³ªÅ¸³¯ ¼ö ÀÖÀ¸¸ç ¿¹ÈÄ¿Í °ü·ÃµÈ´Ù.
14. Rheumatoid vasculitis
polyneuropathy, mononeuritis multiplex, digital gangrene, dermal necrosis, visceal
infarction
ischemic ulcer on lower extremity, myocardial infarction, pericarditis, osteoporosis
** renal vasculitis´Â µå¹°´Ù.
15. mononeuritis multiplex: rheumatoid vasculitis¿¡¼ ÇÑ °³ ȤÀº ±× ÀÌ»óÀÇ »çÁö¿¡¼
patchy sensory losss¼Ò°ßÀ» º¸ÀÌ´Â °Í
16. RA¿¡¼ lung involvement: ³²ÀÚ¿¡¼ ÈçÇÏ´Ù.
1) peural effusion: exudate, glucose¡é, complement¡é, LDH¡è, RF(+)
2) pulmonary fibrosis: restrictive pattern, DLco¡é(large airway´Â ħ¹üÇÏÁö ¾Ê´Â´Ù)
3) necrotizing bronchiolitis: ÁÖ·Î gold, D-penicillamineÄ¡·á·Î ÀÎÇØ À¯¹ß
17. Felty's syndrome: RA + pancytopenia + splenomegaly
high titer RF, long-standing RA¿Í °ü·Ã
18. Felty's syndrome
- °¨¿°Àº G(+)°¡ ¸¹°í neutropeniaÁ¤µµ¿Í °ü·ÃÀÌ ¾øÀ»¼ö ÀÖ´Ù.
- 1/3¿¡¼ ¸»ÃÊ¿¡ large granular lymphocyte°¡ º¸À̹ǷΠLGL syndrome°ú °¨º°ÀÌ ÇÊ¿äÇÏ´Ù.
- splenectomy·Î Ç×»ó neutropenia°¡ ±³Á¤µÇ´Â °ÍÀº ¾Æ´Ï´Ù.
- eosinophilia°¡ ÀÖ´Ù¸é severe systemic disease°¡ ÀÖÀ½À» ÀǹÌÇÑ´Ù.
- Ȱµ¿±â¿¡ CD4+ T cell°ú MHC class II gene expression(HLA DR4)ÀÌ Áõ°¡ÇÑ´Ù.
- Ȱµ¿±â¿¡ CD4+/CD8+ ºñ°¡ Áõ°¡µÇ¾î ÀÖ´Ù.
19. RAÀÇ clinical remission crieria by ACR
¾Æ·¡ 6°¡Áö Áß¿¡¼ 5°¡ÁöÀÌ»óÀÌ 2°³¿ù ÀÌ»ó Áö¼ÓµÇ¾î¾ß ÇÑ´Ù.
i) morning stiffness < 15min
ii) fatigue(-)
iii) joint pain(-)
iv) joint tenderness or pain on motion(-)
v) soft tissue swelling in joint or tendon sheath(-)
vi) ESR : normal
20. °ñÀÇ ÆÄ±«¸¦ ¿¹¹æÇÒ¼ö ÀÖ´Â ¾à: DMARD
- ¼öÁÖ ³»Áö ¼ö°³¿ùµÚ¿¡ Ä¡·áÈ¿°ú°¡ ³ªÅ¸³ª¸ç Á÷Á¢ÀûÀÎ ÁøÅë°ú Ç׿°ÁõÀÛ¿ëÀº ÀûÀ¸¹Ç·Î
NSAID¿Í µ¿½Ã¿¡ Åõ¿©ÇÑ´Ù.
- ÁøÁ¤ÇÑ °üÇØÀ¯µµ´Â µå¹°Áö¸¸ 2/3¿¡¼ È¿°úÀûÀÌ´Ù.
- MTXÄ¡·á½Ã ÃÖ´ëÈ£ÀüÀº Ä¡·á½ÃÀÛ ¾à 6°³¿ù µÚ¿¡ °üÂûµÇ¸ç ±×ÈÄÀÇ Ãß°¡Àû È£ÀüÀº °ÅÀÇ
¾ø´Ù.
21. MTX toxicity
BM suppression, hepatotoxicity, cirrhosis, pneumonitis, oral ulcer,
leukocytoclastic vasculitis, rheumatoid nodule formation¡è
22. hydroxychloroquineÀº ºñ°¡¿ªÀûÀÎ retinopathy¸¦ ÀÏÀ¸Å³¼ö ÀÖÀ¸¹Ç·Î Á¤±âÀû °Ë»ç°¡
ÇÊ¿äÇÏ´Ù.
D-penicillamine˼ SLE, myasthenia gravis, myositis
23. RAÄ¡·á¾àÁß ´Ü¹é´¢¸¦ ÀÏÀ¸Å°´Â ¾à
D-penicillamine, gold
24. systemic corticosteroids°¡ ÇÊ¿äÇÑ °æ¿ì
neuropathy, vasculopathy, pleuritis, pericarditis, scleritis
25. leflunomide(Arava) : pyrimidine antagonist, activated T lymphocyte¾ïÁ¦
ÃÖ±Ù RAÀÇ long-term tx·Î ¼Ò°³
26. etanercept(Enbrel), infliximab(Remicade)
: TNF-¥á¸¦ block½ÃÅ´À¸·Î½á RAÄ¡·á¿¡ Å« È¿°ú°¡ ÀÖÀ½ÀÌ ÀÔÁõµÈ ¾à
27. poor prognostic factor
i) joint damage ¼Óµµ°¡ Ŭ ¶§: uncontrolled polyarthritis, structural damage & deformity
ii) extra-articular feature: subcutaneous nodule
iii) psychosocial problems
iv) RF(+)
v) RA susceptibility gene HLA DR cluster 1°³ÀÌ»ó: DRB1*0401,0404,0405
vi)±×¿Ü, old age at onset, female, ESR, CRP°¡ Áö¼ÓÀûÀ¸·Î ³ôÀº °æ¿ì
28. JRAÀÇ poor prognostic factors
1) polyarthritis: late age, Á¶±â°üÀýħ¹ü, early erosion, Áö¼ÓÀû ¿°Áõ, systemic
manifestations, RF(+), subcutaneous nodule
2) adult pattern of arthritis: MP & PIP joint involve
3) hip joint involve
29. corticosteroid °üÀý³» ÁÖÀÔ
i) pain relief & functional improvement
ii) bony erosionÀ» Áö¿¬½ÃŰÁö´Â ¾Ê´Â´Ù.
iii) ÇѰüÀý¿¡ 3-4ȸ ÀÌ»ó ÁÖÀÔÇÏ¸é ¾ÈµÈ´Ù.
iv) ÁÖÀÔÈÄ 48½Ã°£ÀÇ ÈÞ½ÄÀÌ ÇÊ¿äÇÏ´Ù.
v) µ¿½Ã¿¡ µÎ °üÀý¿¡ ÁÖ»çÇÏ´Â °ÍÀ» »ï°£´Ù.
vi) ÃÖ¼Ò 4°³¿ùÀÌ»óÀÇ °£°ÝÀ¸·Î ÁÖÀÔÇÏ¿© 1³â¿¡ 3-4ȸ À̳»·Î Á¦ÇÑÇÑ´Ù.