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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.