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Rheumatoid Arthritis

Title               

Ñ    Rheumatoid arthritis

Definition

Ñ    Rheumatoid arthritis:

Is a disorder characterised by:

Ñ    Chronic symmetrical inflammatory synovitis

Ñ    Unknown aetiology

Ñ    Involves the peripheral joints

Ñ    Potentially results in destruction of articular and periarticular structures

Ñ    With or without generalised manifestations

Pathogenesis

Causes

Ñ    Unknown

Risk factors

Ñ    Sex hormones:

Probably

Ñ    Familial tendency

Ñ    Immunogenetics (association with certain HLA haplotypes):

·          HLA-DR4:

Poor prognosis

·          HLA-DR b-1:

Increases susceptibility

Pathological Process

Ñ    Inflammation of the synovium

Ñ    Infiltration by cells including polymorphs, lymphocytes, plasma cells

Ñ    Marked vascular proliferation

Ñ    Lining cells of the synovium become hyperplastic and thickened

Ñ    Synovium proliferates into folds and fronds

Ñ    Spreads across the surface of cartilage as a pannus

Ñ    Pannus damages cartilage by interfering with its nutrition and by release of cytokines which damage chondrocytes

Ñ    Cartilage becomes thin and the underlying bone is exposed

Ñ    Fibroblasts from the proliferating synovium grow along the blood vessels into the bone and damage bone

Ñ    This causes bone erosions

Ñ    Erosions lead to deformity and disability

Clinical Features

The presentation of RA may be:

Ñ    Palindromic

Ñ    Transient

Ñ    Remitting

Ñ    Chronic persistent

Ñ    Rapidly progressive

Palindromic

Ñ    Mono-articular attacks which last between 24-48 hours.

Ñ    Recurrent attacks may occur in the same or other joints.

Ñ    50 % go on to develop chronic rheumatoid arthritis.

Ñ    If IgM rheumatoid factor is detected, it predicts progression to chronic arthritis

Transient

Ñ    Self-limiting disease

Ñ    < 12 months duration

Remitting

Ñ    Several years of activity, remits, minimal damage

Chronic persistent

Ñ    Relapsing and remitting course over years

Rapidly progressive

Ñ    Rapid progression over a few years

Ñ    Severe joint damage and disability

Ñ    Systemic complications

Ñ    Seropositive

Ñ    Difficult to treat

History

Age

Ñ    Any age

Ñ    Commonly 30-50 years

Sex

Ñ    Females > Males

E&M

Ñ    Tiredness

Ñ    Unwell

LMS

Ñ    Pain

Ñ    Stiffness

Ñ    Swelling

Examination

IS

Ñ    Subcutaneous nodules

Ñ    Vasculitis

CVS

Ñ    Raynaud’s phenomenon

Ñ    Pericarditis

RS

Ñ    Hoarse voice:

Cricoarytenoid joint involvement

Ñ    Obstructive bronchiolitis

Ñ    Fibrosing alveolitis

Ñ    Nodules

Ñ    Nodules with pneumoconiosis:

Caplan’s syndrome

Ñ    Pleural effusion

Ñ    Pleural nodules

GIT

Ñ    Bowel infarction

HS

Ñ    Anaemia

Ñ    Felty’s syndrome:

RA, splenomegaly, neutropaenia

CNS

Ñ    Ocular complications:

Scleritis

Episcleritis

Dry eyes

Ñ    Cord compression:

Atlanto-axial subluxation

Ñ    Mononeuritis multiplex

Ñ    Glove and stocking sensory neuropathy

Ñ    Compression neuropathy:

Carpal tunnel

Tarsal tunnel

LMS

Ñ    Swelling

Ñ    Redness (rare)

Ñ    Deformity

Ñ    Warmth

Ñ    Tenderness

Ñ    Loss of function

Ñ    Joint destruction

Ñ    Tenosynovitis

Ñ    Bursitis

Ñ    Muscle wasting

Complications

KUS

Ñ    Amyloidosis

LMS

Ñ    Septic arthritis

Investigations

Fluids

Blood

Haematology

Ñ    Anaemia:

·          Anaemia of chronic disease

·          Felty’s syndrome

·          NSAID induced gastrointestinal blood loss

·          Myelosuppression due to drug

·          Drug induced haemolysis

Ñ    ESR:

Raised

Ñ    CRP:

Elevated

Immunology

Ñ    Rheumatoid factor:

IgM antibody against Fc fragment of Ig

Ñ    Anti-cyclic citrullinated peptide antibody (anti-CCP):

Highly specific

Imaging

X-Ray

Ñ    Soft tissue swelling

Ñ    Erosions

MRI

Ñ    Demonstrates early erosions

Management

Symptom relief

Drugs

Ñ    NSAIDs

Control

Drugs

DMARDS

Disease-modifying anti-rheumatic drugs:

Ñ    Sulphasalazine

Ñ    Methotrexate

Ñ    Gold

Ñ    Penicillamine

Ñ    Hydroxychloroquine

Ñ    Leflunomide

Ñ    Azathioprine, cyclophosphamide, ciclosporin:

Less commonly used

Steroids

Ñ    Induce remission

Biological Agents

Ñ    TNF alpha inhibition:

Infliximab

Etanercept

Adalimumab

Support

Surgery

Ñ    Synovectomy

Ñ    Excision arthroplasty

Ñ    Replacement arthroplasty

Lifestyle Adjustments

Ñ    Rest for active arthritis

Ñ    Exercises to maintain joint range and muscle power

Staffing

Ñ    Physiotherapy

Equipment

Ñ    Aids to activities of daily living

Residence

Ñ    Structural changes to housing to facilitate activities of daily living

 

 

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