Case Discussion on Rheumatoid Nodule and Causes

Summary

The video script focuses on the characteristics, diagnosis, and prognosis of rheumatoid arthritis. It covers key aspects such as the identification of rheumatoid nodules, laboratory investigations, and the significance of various tests like RF and anti-CCP antibodies. The speaker explains the interpretation of X-rays and the relevance of acute phase reactants. Additionally, the script discusses the importance of affordability and practicality in testing and imaging, particularly for patients in rural settings.

Takeaways

• 🧑‍⚕️ Rheumatoid nodules are non-painful, subcutaneous, and commonly found on the extensor surfaces of the hands.
• 🩺 Rheumatoid nodules are a characteristic feature of rheumatoid arthritis and a marker of disease activity.
• 🧪 For lab investigations in rheumatoid arthritis, important tests include CBC, ESR, CRP, and rheumatoid factor (RF).
• 🔬 Rheumatoid factor (RF) recognizes the FC portion of the IgG antibody and is positive in 85% of RA patients within the first two years.
• 📉 High titers of RF are associated with poorer prognosis and more extra-articular manifestations.
• 🔍 Other causes of positive RF include vasculitis, sarcoidosis, cryoglobulinemia, and chronic liver diseases.
• 🧫 Anti-CCP antibodies are highly specific (95%) and sensitive (65%) for diagnosing rheumatoid arthritis and have prognostic value.
• 🦠 Inflammatory synovial fluid is identified through needle aspiration and is characterized by markers like elevated APRs and leukocytosis.
• 🩻 Imaging such as X-rays, CT scans, and MRIs are useful for diagnosing and assessing the extent of joint damage in rheumatoid arthritis.
• 🦴 Key radiographic findings in RA include osteopenia, symmetrical joint space narrowing, and marginal subchondral erosions.

Q & A

What are rheumatoid nodules and where are they typically found?

Rheumatoid nodules are subcutaneous nodules that are characteristic features of rheumatoid arthritis, mainly found on the extensor surfaces of the hand. They are non-painful and can be present even if the features of rheumatoid arthritis are not evident.

What does the term 'neutropenia' refer to in the context of lab investigations?

Neutropenia refers to a decrease in the number of neutrophils in the blood, which is a condition that can be assessed through a CBC (Complete Blood Count) and other lab tests like ESR and CRP.

What is the significance of the term 'GBP' in the context of lab investigations?

In the script, 'GBP' seems to be a miscommunication. The correct term might be 'Globulin,' which is a part of blood proteins and can be checked as part of a blood test to evaluate various conditions including rheumatoid arthritis.

What is the role of Rheumatoid Factor (RF) in diagnosing rheumatoid arthritis?

Rheumatoid Factor is an autoantibody that recognizes the Fc portion of IgG. It is present in about 85% of rheumatoid arthritis patients within the first two years of the disease and has prognostic value, with high titers often indicating a poor prognosis and more extra-articular manifestations.

What does the term 'acute phase reactants' refer to in lab tests?

Acute phase reactants are proteins whose concentrations change significantly in response to inflammation. They include CRP (C-reactive protein), ESR (erythrocyte sedimentation rate), and fibrinogen, among others.

What is the significance

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Outlines

00:00

🩺 Understanding Rheumatoid Nodules and Lab Investigations

This section discusses rheumatoid nodules, highlighting their appearance, prevalence, and characteristics. It emphasizes that these nodules are non-painful, subcutaneous, and commonly found on the extensor surfaces of the hand. The discussion then shifts to lab investigations necessary for diagnosing rheumatoid arthritis, such as complete blood count (CBC), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF). The importance of distinguishing between various antibodies, such as IgG and IgM, and understanding their roles in disease activity and progression is also covered.

05:02

🧬 Prognostic Value and Other Causes of Rheumatoid Factor

This paragraph explains the prognostic value of rheumatoid factor (RF) and its role in rheumatoid arthritis (RA). It notes that about 85% of RA patients become RF positive within the first two years, and high RF levels are associated with poor prognosis and extra-articular manifestations. Other causes of RF positivity, such as vasculitis, sarcoidosis, and chronic liver diseases, are mentioned. The importance of NTCCP antibodies in diagnosing and predicting the severity of RA is also highlighted, with emphasis on their diagnostic and prognostic value.

10:03

🔬 Synovial Fluid Analysis and Imaging for RA Diagnosis

This section covers the analysis of inflammatory synovial fluid, including how to aspirate it and its significance in diagnosing RA. It discusses the role of imaging, such as CT scans and MRIs, in detecting joint and bone abnormalities. The paragraph stresses the importance of considering patients' affordability before recommending expensive tests and highlights the basic investigations that should be performed initially.

15:05

🦴 Bone and Joint Space Abnormalities in RA

This paragraph focuses on identifying bone and joint space abnormalities in RA through X-rays. It describes osteopenia, marginal subchondral erosions, and symmetrical joint space narrowing. The importance of these features in diagnosing RA and understanding disease progression is emphasized. The section also mentions subluxation and its implications for joint health, particularly in the atlanto-axial joint, where ligament loosening can cause spinal cord compression.

Keywords

💡Rheumatoid

Rheumatoid refers to rheumatoid arthritis, a chronic autoimmune disorder that primarily affects joints. In the video, it is the central theme, with discussions on its characteristics, diagnosis, and treatment. For example, the script mentions 'rheumatoid nodule' and 'rheumatoid arthritis' as part of the diagnostic criteria and disease activity markers.

💡Subcutaneous nodules

Subcutaneous nodules are lumps that form under the skin and are a characteristic feature of rheumatoid arthritis. The script specifies that these nodules are non-painful and mainly found on the extensor surfaces of the hand, indicating the visibility of the disease's physical manifestations.

💡Neutropenia

Neutropenia is a condition characterized by an abnormally low count of neutrophils, a type of white blood cell. In the context of the video, it is mentioned as a lab investigation that may be relevant for patients with rheumatoid arthritis, indicating a connection between the disease and blood cell abnormalities.

💡Acute phase reactants

Acute phase reactants are proteins whose levels increase in response to inflammation. The script mentions CRP and ESR as examples, which are used to assess disease activity in rheumatoid arthritis, highlighting their importance in monitoring the inflammatory process.

💡Rheumatoid factor (RF)

Rheumatoid factor is an autoantibody that targets the Fc portion of IgG antibodies. The script explains its diagnostic significance, as 85% of rheumatoid arthritis patients test positive for RF within the first two years of the disease, and its prognostic value, as high titers are associated with poor outcomes.

Highlights

Rheumatoid nodules are subcutaneous, non-painful, and mainly found on the extensor surfaces of the hand, seen in 20% of rheumatoid arthritis cases.

Lab investigations for rheumatoid arthritis include CBC, ESR, CRP, RF, and

Transcripts

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as I told

what is uh

you said rheumatoid you can see that

what is rheumatoid see the picture

player carefully just

what do you see in a picture

what a remote you see it

these are the repression comes to you

with such characteristics

what kind of module it is what kind of

swelling it is tell me

so have you seen any patient with such

thing anyone have you seen a patient

with the rheumatoid nodule ever

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these are uh form in nature okay seen in

like uh 20 percent of the cases

and these are non-painful these are not

painful okay there are uh these are

subcutaneous nodules and mainly found on

the extensor Services of the hand okay

it is a characteristic feature of the

rheumatoid arthritis okay and a marker

of a disease activity and can be present

even if the features of rheumatoid

arthritis are upset

so but so coming up to the lab

investigations okay as I told

neutropenia so for that you need to do a

cbct lcdlc check for HB ESR and GBP

what is GBP

what do you understand by GBP

anyone

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was broken I guess

yes the presentation is not visible yeah

yeah it has gone actually that's why

sorry yeah divisible right yes it is

visible house okay

no no no no no government in peptide

yeah for the medicine party right

put a common sense in this I am asking

about lab investigation now why would

you write a gamma paint in peptide

just don't Google please

and uh what are the next things uh acute

phase reactants

pneumatized factors

okay RF and ntccb antibodies I'll tell

you in a quick uh like what is a

rheumatoid factor is that it recognizes

the FC portion of the IGG

does anyone know what is FC portion

what is the FC portion of the antibody

you must have read the antibody diagrams

AFC portion is the renewable antibody

diagram it is responsible that is for

the biological activity so just remember

it recognizes a fc portion of the IGG

immunoglobulin can be IGM IGG IGA and uh

85 percent see gross patients like 85

percent with ra over the first two years

become RF positive okay

the negative may be repeated four to six

months for the first two years of the

disease and may take 18 to 24 months to

become zero positive okay so keep in

mind that

so what is its prognostic valuation with

high titles of our average General tend

to have poor progresses more extra

articular manifestation

okay so 85 percent of people

you see there are there becomes RF

positive for the first two years and the

prognostic value is and with the high

titles of RF there is a poor prognosis

and most many like extraordicular

manifestations are presented with the

patient

so next is uh what do you see is

causes of the positive like what are the

other causes also

these rheumatoid arthritis as children

vasculitis sarcoidosis

cryoglobulemia chronic liver diseases

so you should know all these but other

things can cause pneumatite Factor

positive for the patient so for all this

is all for the exam point of view

so ntccp okay

so IGG against synovial membrane peptide

damage via inflam inflammation

and sensitivity is 65 and specificity is

95 so it is highly uh recommended and it

is both Diagnostic and have a prognostic

value so as I told patient you are

writing for an RI Factor so you should

always suggest energy ccb2 right away

and you should always

correlate it accordingly

so predictive of erosive disease

disease severity Radiology progression

and poor function what is uh what you

understand of erosive disease

in medical terms what does the meaning

of erosive

anyone

so erosive yes someone is right

destruction this is good very nice

so as you understand erosion means there

is a destruction

okay there is a bone erosion and there

is a uh it leads to what we call

functional decreased functional capacity

and the joint damage for the patients

next acute phase reactants you see

there is a mild elevation to moderate

and to marked elevation positive acute

phase Okay negative with albumin

transparent positive is mild elevation

you see celluloplasmin complement C3 C4

mild it comes to have to globulin

fibrinogen Alpha One and Alpha One

protease and acid lipoproteins marked

elevation you see is CRP serum alert a

protein

so uh see you can don't get all the

tests at all the centers some people

might be working in a government

periphery suppose I am work I am also

working it so what are the common tests

you can write

which which is available easily to

everyone

name a few tests

that you will write you suspect a

patient is suffering from osteoarthritis

oh sorry limited arthritis

crb ESR good

are effective good

three next

CRP ESR artifactor

IGG

uh is it available at your place IGG if

you're working at a hospital

artificial yes

CBC ESR CRP r a vector and

one one is missing

most important

as I told ntccp good these are the

common tests you should always write

anywhere you are okay so for a good

corporate setups you see everything

every test is available this test in

government setups are available for free

and you can suggest uh to patients for

the same

next

the other abnormalities elevated aprs

that

esrcrombocytosis leukocytosis Ana 30 to

40 percent

antinuclear antibodies inflammatory

synovial fluid and hypoalbum anemia so

how would you know it is an inflammatory

synovial fluid

how would you know that

you have written level normal it is how

how did I get to know what is

inflammatory cyanobic fluid what will I

do for that

the CRP okay

no no so synovial fluid

aspirations

you need to say word aspiration synovial

fluid with needle aspirations good yes

as period the synovial fluid so uh I'll

uh there's a question for you do you

think CT scan for a knee joint will be

helpful for this to know that a person

is suffering from any synovial fluid as

inflammation

the other cities can help for it or an

MRI

a CT an M or an MRI for the patient

what you will write for a patient

but you'll write a CT

uh

how many of you are working in a rural

setup

anyone working in a rural setup

well I'll suggest you people is before

writing a CT an MRI always always ask

for a affordability for the patient

first

you never know how what kind of a

patient is there who's coming to you ask

for the affordability not every doctor

can a spirit synovial fluid so basically

always go with the basic investigations

first and if you suspect that this

disease has worsened then you can

suggest for an author review then you

can go for a city or an MRI okay

so next

okay tell me you see ABC bonds what do

you see in a bone when you see in a b

and what do you see in a c

I'll I'll check what is the presence of

mind for you people you will get I'll

get to know now but you see in an a bone

b and a c

among the one

I'm gonna replied erosion in the sea

very nice

and what for a and b

so uh

and Monika tell me what kind of erosion

it is is it a marginal or it is complete

and what kind of

erosions

what kind of erosion do you see it is a

marginal or a complete erosion

yes good

see it is marginal you see that it is a

marginal and it is a subchondral erosion

always remember and for the a bone what

is in the a bone

what do you see in the a bone

anyone

osteopenia

very nice

how do you define it as an osteopenia

but how do you see it is an osteopenia

area okay see osteopenia what do you

understand there is a bone loss okay you

see there is a lot of bone loss you can

see good for the two you have replied

tell me for the B

what is what has happened in the B

for the B

and declamation

okay

see I'll tell you

see you can see there is a joint space

okay

you can see joint space here

what kind of joint space do you see here

is it symmetrical or asymmetrical first

of all

other bones symmetrical or asymmetrical

there is symmetry in them but there is

no symmetry in them

see the diagram carefully

there is no symmetry

anyone else

see the bone is symmetrical only see the

joint space you see that

but

what are the bone spaces narrowed or are

the bone spaces wide and tell me

what is a uh like joint species are

narrowed yes chord word so there is a

narrowing of bone spaces but it is in a

symmetrical way now you understand me

everyone

you understood all the ABC diagrams very

well so now you can easily check for the

X-ray and you can diagnose it well so

for the AUC there is an osteopenia

see what you see is in the bone B part

say there is a narrow what we say is

narrow

joint space symmetry but it is

symmetrical okay

and it is uniform

okay it is not on the one side or the

other side there is a symmetry of the

joint okay and it is uniform in nature

and also there is a

narrowing of the joint space okay

for the a it is ostominium for the B it

is uniform symmetric joint space

narrowing and for the C it is marginal

subchondral erosions

next okay what do you see in such

pictures

there is a

I'll be quick on this

see this you see that as I told

there is a subluxation you see that

understood everyone there is a

subluxation of the

joints

okay

yes

here you see that

this is Atlanta x equals axial joint

there is a loosening of the ligaments

and thickening which is causing the cord

compression you see

when they are compressing the card

see how beautiful it is written as you

can see that

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