Rheumatoid Arthritis

Rheumatoid Arthritis
Presentation by: Anand Lal, M.D.


Rheumatoid Arthritis

* Chronic systemic inflammatory disease of unknown etiology
* Affects the Synovial Membranes of multiple joints
* Prevalence 1-2%
* Female : Male ratio 3:1
* Usual age of onset 20-40 years though individuals of any age group may be affected
* Pathologic finding: chronic synovitis with pannus formation. The pannus erodes cartilage, bone, ligament and tendons. In the acute phase effusion and other manifestations of inflammation are evident; in the later stages ankylosis of the joint may set in. In both the acute and chronic phase, there may be widespread inflammation of the tissues around the joint that can lead to significant joint destruction.

* Clinical presentation
o usually presents insidiously;
o prodromal syndrome of malaise, weight loss and vague periarticular pain and stiffness may be seen
o less commonly, the onset is acute, triggered by a stressful situation such as infection, trauma, emotional strain or in the postpartum period.
o the joint involvement is characteristically symmetric with associated stiffness, warmth tenderness and pain
* Clinical Features
o the stiffness is characteristically worse in the morning and improves during the day; its duration is a useful indicator of the activity of the disease. The stiffness may recur especially after strenuous activity.
o the usual joints affected by rheumatoid arthritis are the metacarpophalangeal jts, the PIP jts, the wrists, knees, ankles and toes.
o Entrapment syndromes may occur especially carpal tunnel syndrome

* Labs
o Rheumatoid factor, an IgM antibody is seen in the sera of 75% of patients with rheumatoid arthritis. High titers of rheumatoid factor are associated with severe disease.
o Rheumatoid factor is also found in other diseases like syphilis, sarcoidosis, infective endocarditis, TB, leprosy, parasitic infections; in advanced age and in asymptomatic relatives of patients with rheumatoid disease.
o Antinuclear antibody are seen in 20% of patients with rheumatoid arthritis, though their titer is lower than in SLE

* Labs
o The ESR is elevated both in the acute and chronic phases of the disease
o a moderate anemia is often present which is usually hypochromic normocytic
o the white count is normal or slightly increased but leukopenia may occur, often in presence of splenomegaly (e.g., Felty’s syndrome)
o the platelet count is often elevated in proportion to the degree of joint inflammation
o joint fluid examination is valuable. The fluid is translucent to opaque and has between 3000 and 50,000 WBCs /microL. There are 50% or more polymorphonuclear leukocytes. The culture is negative.

* X-ray
o of all the laboratory tests, x-ray changes are most specific for rheumatoid arthritis. However, they are not sensitive and usually are negative during the first 6 months of the disease

* X-rays
o the earliest changes occur in the wrist or feet and consist of soft tissue swelling and juxta-articular demineralization. Later, diagnostic changes consisting of joint space narrowing and erosions develop. The erosions are first seen at the ulnar styloid and at the juxta-articular margin, where the bony surface is not protected by cartilage. Diagnostic changes also occur in the cervical spine with C1-2 subluxation, but this can take several years to develop.

* Differential Diagnosis
o Rheumatic fever: migratory arthritis, elevated ASO and dramatic response to Aspirin
o Systemic Lupus Erythematosus: Butterfly rash, discoid lupus erythematous, photosensitivity, alopecia, high titers of Anti Ds-DNA, renal and CNS disease
o Osteoarthritis: no constitutional manifestations and no evidence of joint inflammation
o Gouty Arthritis: usually monoarticular initially but can become polyarticular in the later years
o Pyogenic arthritis: usually monoarticular, fever and chills, abnormal joint fluid
o Chronic Lyme disease: commonly monoarticular and associated with positive titers
o Human Parvovirus infection: arthralgia more common than arthritis, rash may be present, serologic evidence of parvovirus B19 infection
o Polymyalgia rheumatica is associated with proximal muscle weakness and stiffness
o several cancers produce paraneoplastic syndromes including polyarthritis; e.g., hypertrophic pulmonary osteoarthropathy produced by lung and gastrointestinal cancers. Diffuse swelling of the palmar fascia has been associated with several cancers including ovarian cancer.

* Treatment
* Treatment (Disease Modifying Agents (DMARDs)
* Prognosis
Rheumatoid Arthritis.ppt