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 Causes Symptoms Diagnosis and Treatment

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.