Rheumatoid Arthritis

Nora Haj-Ali
 Arthritis
• Joint inflammation and swelling
• Many types
• Osteoarthritis
• Rheumatoid arthritis
• Others
• Diagnosis may involve
arthrocentesis
• Aspiration of synovial fluid
• Used for diagnosis in some cases
• Also therapeutic for large effusions

SCGH ED CME/Slideshare
 Arthriti
sClassification
• Non-inflammatory
• Degenerative arthritis
• Usually due to osteoarthritis
• Joint pain without warmth or swelling
• Low WBC in synovial fluid
• May cause brief < 30 min morning
stiffness
Disease White Blood
• Inflammatory Count (cells/mm3)
• Warm, swollen joints
• Elevated WBC in synovial fluid Normal < 200
• Prolonged (>30 min) morning stiffness Osteoarthritis 200-2000
Inflammatory > 2000
 Arthriti
sClassification
• Number of joints
• One: monoarthritis
• Two to four: oligoarthritis
• More than five:
polyarthritis
 Rheumatoid Arthritis
• Autoimmune inflammation of synovium
• Thin layer of tissue (few cells thick)
• Lines joints and tendon sheaths
• Secretes hyaluronic acid to lubricate joint space
• Systemic disease with extraarticular
complications
• More common in women
• Usual age of onset 20 to 40 years
• Disease course may wax and wane with flares
Pathophysiology
Certain interstitial tissue proteins (e.g.
intracellular filament protein vimentin,
filaggrin, type II collagen) undergo a
posttranslational modification that
involves the conversion of arginine to
citrulline (citrullination).

Citrullinated proteins are recognized as

foreign by the antigen-presenting cells that
present them to CD4+ T cells.
Pathophysiology
Activation of CD4+ T cells leads to the following sequences of events:

IL-4 production → B-cell proliferation and differentiation → production of

anticitrullinated peptide antibodies → type II hypersensitivity reaction and
type III hypersensitivity reaction

Migration of CD4+ T cells to synovial joints → secretion of cytokines (IFN- γ,

IL-17) → recruitment of macrophages → secretion of cytokines (TNF- α, IL-1,
IL-6) → inflammation and proliferation
Pathophysiology
Bouts of inflammation, angiogenesis, and proliferation → proliferative granulation
tissue with mononuclear inflammatory cells → pannus and synovial hypertrophy →
invasion, progressive destruction, and deterioration of cartilage and bone

Antibodies against Fc (fragment crystallized) portion of IgG (rheumatoid factor, RF)

are produced to aid in removing autoantibodies and immune complexes.

RF excess triggers formation of new immune complexes and type III HSR

Individuals with positive RF are more likely to develop extraarticular

manifestations.
 Rheumatoid Arthritis
Clinical features
• Symmetric joint inflammation
• Gradual onset
• Pain, stiffness, swelling
• Classically “morning stiffness”
• Joint stiffness >1 hour after rising
• Improves with use
• May have systemic symptoms
• Fever, fatigue, weight loss
 Rheumatoid
Arthritis
Clinical features
• Most often involves wrists and hands
• Classically affects MCP and PIP joints of
hands
• Often tender to touch
• DIP joints spared
• Contrast with osteoarthritis – DIP joints involved
• Lumbar spine usually spared
• Also a contrast with osteoarthritis

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Joint Deformities
Swan neck
deformity
Boutonnier
e
deformity
Rheumatoid Foot
 Rheumatoid
Arthritis
Clinical features
• Bones can erode and deviate
• Ulnar deviation
• Swelling of MCP joints 🡪
deviation
• Swan neck deformity
• Hyperextended PIP joint
• Flexed DIP

Phoenix119/
Wikipedia

Www.Medicalstudyz
 Rheumatoid
Arthritis
Clinical features
• Axial spine spared except cervical region (usually C1 to
C2)
• “Atlantoaxial joint”
• Occurs with longstanding disease
• Neck pain and stiffness
• Cervical
subluxation
• Possible life-threatening spinal cord compression
• May require surgical treatment
• Limited by DMARD therapy
• Cervical spine X-ray before surgery in RA patients
• Risk of neurologic injury with intubation
West Chiropractic Clinic & Neuropathy @WestChiroClinic

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 Rheumatoid
Arthritis
Clinical features
• Baker's cyst (popliteal cyst)
• Swelling of gastrocnemius-semimembranosus bursa
• Synovium-lined sac at back of knee continuous with joint
space
• Common in patients with OA or RA of knee
• Often asymptomatic bulge behind knee
• If ruptures 🡪 symptoms similar to DVT
• Posterior knee pain, swelling, ecchymosis
• Usually a clinical diagnosis
• May need to rule out DVT

Www.Medicalstudyz
 Rheumatoid Arthritis
Extraarticular features
Interstitial Lung Disease
• Serositis – inflammation of serosal
surfaces
• Pleuritis 🡪 pleural effusion
• Pericarditis 🡪 pericardial effusion
• Parenchymal lung disease
• Interstitial fibrosis
• Pulmonary nodules
• Carpal tunnel syndrome
• Anemia of chronic disease
Rheumatoid Arthritis
Extraarticular features
• Palpable nodules common (20 to 35%
patients)
• Pathognomonic for rheumatoid arthritis
• Common on elbow although can occur
anywhere
• Usually no specific treatment

PHAM HUU THAI/Slideshare

Rheumatoid Arthritis
Extraarticular features
• Episcleritis and scleritis
• Red eye
• Eye pain
• Discharge
• Sjogren’s syndrome
• Common in patient’s with
RA

Image courtesy of Kribz

Rheumatoid
Arthritis
Osteoporosis
• Accelerated by RA
• Also often worsened by steroid
treatment
• 30 percent ↑ risk of major fracture
• 40 percent ↑ risk hip fracture
 Rheumatoid Arthritis
Diagnosis
• Inflammatory arthritis of 3 or more joints lasting more than 6
weeks
• Rheumatoid factor (RF) – 70 to 80% of patients
• Low specificity – elevated in some normal patients and other conditions
• Antibodies to citrullinated peptides (ACPA)
• More specific
• Acute phase reactants
• Elevated C-reactive protein (CRP) or erythrocyte sedimentation rate
(ESR)
Imaging - X-ray
Baseline radiographs of both hands (dorsopalmar view) and feet

Radiographs of symptomatic joints

Findings

Early: soft tissue swelling, osteopenia (juxtaarticular)

Late: joint space narrowing, marginal erosions of cartilage and bone,

osteopenia (generalized), subchondral cysts
 Rheumatoid Arthritis
Treatment
• Traditional disease-modifying antirheumatic drugs
(DMARDs)
• Protect joints from destruction
• Provide long term reduction in disease progression and complications
• Slow onset of effect over weeks
• Usually given as oral drugs
• Pain control
• Bridging therapy until DMARDs take effect
• NSAIDs – drug of choice for pain control
• Corticosteroids used if NSAIDs inadequate for pain control
• Short term steroid treatment used for symptom flairs
DMARDs
Disease-modifying antirheumatic
drugs
• Methotrexate
• Best initial DMARD
• May cause bone marrow suppression
• Co-administered with folic acid
• Also causes hepatotoxicity and
stomatitis Methotrexate

• Monitor CBC, LFTs and creatinine

• Hydroxychloroquine
• Sulfasalazine
• Leflunomide
 Biologics
• Antibody-based treatments
• Infusions or injections
• Used when methotrexate does not control
disease
• Anti-TNF alpha therapy
• Etanercept and infliximab
• Non-TNF biologics
• Abatacept, rituximab, tofacitinib
• Pre-treatment screening for latent TB
• Also hepatitis B and C

Public Domain
Rheumatoid Arthritis
Long Term Complications
• Increased risk of coronary
disease
• Leading cause of mortality
• Secondary (AA) amyloidosis

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Felty Syndrome
• Syndrome of splenomegaly and neutropenia in RA
• Low WBC on blood testing
• Increased risk for bacterial infections
• Abdominal pain from enlarged spleen
• Classically occurs many years after onset RA
• Usually in patient with severe RA
• Joint deformity
• Extra articular disease
• Improves with RA therapy

Wikipedia/Public
Domain