RHEUMATOID ARTHRITIS(RA)

• Introduction:

 It is a chronic inflammatory disorder affecting many joints, including those in the hands and feet.

  RA can also affect other tissues throughout the body and cause problems in organs such as the lungs, heart, and eyes.

   In RA the body's immune system attacks its own tissue, including joints and  In severe cases, it attacks internal organs also.

• Defination :

       Rheumatoid arthritis (RA) is a multisystem inflammatory disease primarily affecting the synovium and adjacent tissues.

• Cause/Etiology:

  - Unknown

  - Immunogenic factors

  - hormonal factors: Incidence of it in  women is greater before menopause and remission of it during pregnancy is well known.

   - OCP 

   - low socio - economic status

   - viral and bacterial infection triggers the RA.

• Risk factors:

  

  - Age: 40-60 year 

  - sex: most common in women than men.

  - Genes/family history

  - weight: over weight

  - smoking 

• Pathogenesis:

-Once the inciting agent has activated the immune system, a range of intersecting immunological pathways operate that causes eventually joint destruction.

- Joint deformity occurs in RA because the cartilage and then the bone is eroded by the proliferative synovial tissue.

-  This process leading to increased laxity of ligaments around the joints, 

subluxation of tendons and subsequently of joints, and 

inflammation of many other tissues in the body.

• clinical Features :

   -The disease commonly presents in the 

   metacarpophalangeal joints or      metatarsophalangeal joints, wrist , inter phalangeal joints,knee joint.

  - morning stiffness is common earliest feature.

  - loss of joint function

  - joint pain

  - joint swelling 

  - joint stiffness

  - tender joint 

  - fever

  - fatigue and tiredness

  - weakness

  - warm joint

• Types of Presentation of RA:

 

1. Classical – Pain, stiffness and swelling of small joints of hands and wrists. Symptoms fluctuate in severity from day to day.

2. Palindromic – Intermittent episodes of pain, swelling 

and redness, usually of a single joint, followed by rapid 

return to normal after several days.

3. Systemic – Weight loss, pleurisy and pericarditis but 

minimal joint involvement.

4. Polymyalgic – Pain and stiffness in shoulders and hips 

with subsequent synovitis.

5. Monoarthritic – Single joint involvement, usually involve the 

knee.

6. Acute onset – Sudden overnight onset with stiffness and pain.

7. With generalized lymphadenopathy.

• Specific Organ Involvement in RA:

✓Cutaneous – Livedo reticularis, palmar erythema, pyoderma gangrenosum.

✓Subcutaneous nodules- occurrs over bony prominences, at sites of pressure or 

friction, ex. elbow.

✓Myositis – Muscle wasting around inflamed joints

✓Vascular – Vasculitis

✓hematologic –Anemia, lymphadenopathy

✓Cardiac –Mitral regurgitation, Pericardial effusion,Constrictive pericarditis.

✓Respiratory system –Pleurisy and pleural effusions,Rheumatoid nodules,Obliterative bronchiolitis, pulmonary hypertension etc.

✓Neurological- neuropathy,cervical  cord compression, cervical nerve root compression etc.

✓Ocular – Keratoconjunctivitis sicca, Episcleritis, scleritis.

✓Renal- Proteinuria, sterile pyuria, microscopic hematuria.

✓Reticuloendothelial system-Splenomegaly,

Oedema, generalized lymphadenopathy.

• Investigation:

 -test for inflammation:✓Raised ESR,                    

                                         ✓C-reactive protein

                                         ✓plasma viscosity

 - Immunological test : ✓ Rheumatoid factor ,

                                         ✓ Anti ccp  (Anti-cycliccitrullinated peptides)

 -Radiology: ✓x-ray,

                      ✓CT etc.

 -special investigation :  ✓synovial biopsy

                                           ✓synovial fluid exa.

                                           ✓Arthroscopy

                                           ✓ Renal biopsy

                                           ✓Pulmonary biopsy

• Criteria for diagnosis of rheumatoid arthritis :

Criterion                                                     Score

+Joints affected

✓1-large joint                                                   0

✓2-10 large joints                                            1

✓1–3 small joints                                            2

✓4–10 small joints                                         3

✓> 10 joints (at least 1 small joint)              5

+Serology

✓Negative RF and ACPA                                0

✓Low positive RF or ACPA                             2

✓High positive RF or ACPA                            3

+Duration of symptoms

✓< 6 weeks                                                      0

✓> 6 weeks                                                      1

+Acute phase reactants

✓Normal CRP and ESR                                  0

✓Abnormal CRP or ESR                                 1

Patients with a score ≥ 6 are considered to have definite RA

• Complication:

✓Osteoporosis

✓Rheumatoid nodules

✓Carpal tunnel syndrome

✓Heart problems

✓Lung disease

✓Lymphoma

✓Vasculitis

                                        

• Diffrential diagnosis:

✓ Infectious arthritis – Viral(rubella,rhinovirus type 7, echovirus, E-B virus, hepatitis C), bacterial (Mycoplasma, Lymedisease)

✓B27-associated arthropathies, which usually present as oligoarthropathy (psoriatic, reactive and enteropathic)

✓Crystal arthropathies – Gout and calcium pyrophosphate dihydrate deposition disease .

• Management:

✓ General measure :

          - education about disease

          - exercise

          - physiothery/occupational therapy

          - Dietary advice

✓Pharmacotherapy:

     • NSAIDs:

      -Ibuprofen ,benoxaprofen, naproxen.

      -piroxicam,meloxicam

      -Diclofenac,Aceclofenac

      -nabumatone

      Etc.

   • DMARDs:

    -Hydroxychloroquine

    -D-penicillamine

    -Methotrexate

    • corticosteroid:

      -Prednisolone

     • Immunosuppressants:

      -Azathioprine

      -Leflunomide

      -Cyclosporine

      -Cyclophosphamide

✓Other Treatments:

  -Stem cell transplantation

  -Plasmapheresis

✓surgery:

 -arthroplasty

 -Synovectomy

 -neurosurgery