Rheumatoid Arthritis Causes Symptoms Diagnosis and Treatment
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.
- · Microvascular injury
- · T-Iymphocyte – CD4+ T cells found
- · HlA DR + macrophages
- · Autoimmune inflammatory process.
Rheumatoid Arthritis Clinical manifestations
- 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.
- · 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
- · 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.
- 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,
- Reconstructive, arthroplasties, joint replacement, synovectomy.