Rheumatoid Arthritis Causes Symptoms Diagnosis and Treatment

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic multisystem disease. There are systemic manifestations.

• There is persistent inflammatory synovitis. chronic systemic disease marked by inflammation of multiple synovial joints,Involves peripheral joints symmetrically. There is damage of cartilage and bone.
• Patients typically complain of joint stiffness in the morning rather than after activities. Women are affected 3 times more often than men.
• Female: Male ratio is 3 : 1
• Age: 35-50 yrs.
• There is genetic predisposition
• Association with rheumatoid factor-auto antibody. HlA-DR4 is major genetic risk factor for RA. Polymorphism in TNF (Tumor Necrosis Factor) and interleukin (Il) 10 genes are seen.

Rheumatoid Arthritis Etiology

• · Unknown
• · Genetic
• · Autoimmune
• · Infectious agent-Mycoplasma, Epstein Barr Virus, Cytomegalovirus, Rubella virus
• · Molecular mimicry
• · Super antigens
• · Cigarette smoking
• · Environmental factors.

Pathology

• · Microvascular injury
• · T-Iymphocyte – CD4+ T cells found
• · HlA DR + macrophages
• · Autoimmune inflammatory process.

Rheumatoid Arthritis Clinical manifestations

Symptoms:

• Joint pains, morning stiffness,
• gelling (stiffness that returns after the patient sits or rests),
• malaise, and fatigue are often present.
• · Chronic polyarthritis begins insidiously
• · Fatigue, anorexia, weakness
• · Musculoskeletal weakness and pain
• · Synovitis – swelling, tenderness and limitation of motion.
• · Arthritis of hands, wrists, knees, feet-loss of function.
• · Symmetrical involvement.
• Systemic: Fatigue, depression, malaise, anorexia,
• rheumatoid nodules, ocular disease, lymphadenopathy,
• splenomegaly, entrapment neuropathies, osteoporosis.
• Constitutional symptoms-Fever, lymphadenopathy, splenomegaly.
• Pain, swelling, tenderness of joints.
• Generalized stiffness, Morning stiffness more than 1 hour.

Description of Arthritis

• · Joint inflamed, held in flexion.
• · Joints involved are proximal interpharyngeal, metacarpopharyngeal, distal interpharyngeal, wrist, elbow, knee, ankle, axial spine.
• · There is swelling, pain, synovitis, deformity, laxity of tissues.
• · Characteristic changes are radial deviation of wrist, ulnar deviation of digits, hyperextension of interphalangeal joints.

Extra–articular involvement

• · Rheumatoid nodules-found near joints, extensor surfaces, pleura, meninges
• · Skeletal muscle atrophy
• · Rheumatoid vasculitis
• · Polyneuropathy
• · Cutaneous vasculitis
• · Myocardial Infarction
• · Renal disease
• · lymphadenopathy
• · Splenomegaly
• · Interstitial fibrosis-lungs
• · Caplan’s syndrome – diffuse nodular fibrotic le­sions in lung
• · Episcleritis
• · Felty’s syndrome-chronic rheumatoid arthritis, splenomegaly, neutropenia, anaemia, thromb­ocytopenia
• · Osteoporosis.

Rheumatoid Arthritis Diagnostic Tests

• Lab tests

• · No specific tests
• ESR: Usually elevated
• C-reactive protein: Unspecific, direct measure of impact of IL-6 on liver cells
• Rheumatoid factor (RF): >1:80 in 70–80% of patients with RA (most commonly IgM Ab)
• · Rheumatoid factor positive
• · Normochromic normocytic anaemia
• · Increased ESR
• · Increased C-reactive protein
• · Synovial fluid analysis – turbid, increased pro­tein, decreased glucose, WBC increased.

• Imaging —

• X–ray
  • Radiographic abnormalities are very useful in the diagnosis and treatment.
  • Periarticular osteopenia is the earliest change.
  • Typical deformity seen in the joints affected.
• CT Scan, MRI
•  mTc biphosphonate bone scan

Rheumatoid Arthritis Differential Diagnosis

• Vasculitis: Behçet syndrome
• Seronegative polyarthritis
• Erosive osteoarthritis
• Chronic infections: Lyme disease
• Other systemic connective tissue diseases:
• Sjögren syndrome, systemic lupus erythematosus, systemic sclerosis, adult Still disease, mixed connective tissue disease
• Psoriatic arthritis
• Viral-induced arthritis: Parvovirus B19, hepatitis C (with cryoglobulinemia)
• Occult malignancy

Rheumatoid Arthritis Treatment

• Relief of pain
• Reduce inflammation Restore function
• Treat systemic features Protection of joints.
• Start DMARDs within 2 months of diagnosis if patient has ongoing active disease despite appropriate dose of aspirin or other NSAIDs.
• Precautions: Offer proton pump inhibitors (PPIs) for chronic NSAID therapy; avoid NSAID combination.
• Relief of Pain
  • · NSAIDs (Ibuprofen, aceclofenac, nimuselide).
  • · COX-I! inhibitors (Rofecoxib, valdecoxib – not approved by FDA).
• Reduce inflammation
  • Glucocorticoids. Intraarticular glucocorticoids.
• Disease modifying Antirheumatic drugs (DMARDs)
  • Methotrexate, Gold compounds, Antimalarials, Sulfasalazine.
  • Methotrexate (MTX) (Rheumatrex): 7.5–25 mg per week PO
• Immunosuppressive/ cytotoxic drugs Omega-3 fatty acids
  • Leflunomide (Arava): Dose: 10–20 mg/d. Modifies T-cell function to decrease autoimmune activity,
• Surgery
  • Reconstructive, arthroplasties, joint replacement, synovectomy.