1- RA

• Rheumatoid Arthritis


  • Peak: 30-50 years old
  • Women 3 times higher risk
• Risk factors


  • Family history
  • Genetic HLA-DR4
  • Smoking
• Pathology of Rheumatoid Arthritis

  1. Synovitis (inflammation of synovial lining)

  2. Thickening of synovial lining & infiltration by inflammatory cells

  3. New synovial blood vessels (by angiogenic cytokines)

  4. Pannus formation due to proliferation of synovium over surface of cartilage

  5. Destroys articular cartilage & subchondral bone

  6. Bone erosions
• Joint Involvement


  • Insidious onset pain, worse with rest and better with activity
  • Morning stiffness > 30 mins at least
  • Symmetrical swelling in small joints of hands and feet à spindling of fingers (swelling in PIPs and MCPs but sparing of the DIPs)
  • Joint instability/ subluxation
  • Joint effusion
• If disproportionate involvement of single joint à must rule out septic arthritis
• Other joints that may be involved

  • Wrists
  • Shoulders
  • Knees
  • Ankles
  • Cervical spine (atlanto-axial subluxation à must do a cervical spine x-ray before intubation)
• Rheumatoid subcutaneous nodules in 20% on pressure areas/bony prominences: elbow, Achilles tendon, finger joints
• Periarticular involvement


  • Bursitis
  • Tenosynovitis
  • Muscle wasting
• Joint Deformities


  • Boutonniere: flexion of PIP, hyperextension of DIP
  • Swan-neck: flexion of DIP, hyperextension of PIP
  • Z-shaped thumb: MCP flexes & IP hyperextends
  • Ulnar deviation (natural direction of hand)
• Hematological


  • Anemia (may be due to chronic disease, NSAID use à GI bleed, hemolysis, hypersplenism)
  • Felty's syndrome: RA, splenomegaly, neutropenia
• Cardiac


  • Pericarditis, pericardial effusion
  • Accelerated atherosclerosis (increased mortality)
• Neurological

  • Entrapment neuropathy (carpal tunnel syndrome)
  • Cervical myelopathy (atlantoaxial subluxation)
  • Peripheral polyneuropathies, mononeuritis multiplex
• Vasculitis


  • Leg ulcers, nail infarcts, gangrene of fingers, toes, bowel, or peripheral nerves
• Renal


  • Amyloidosis, analgesic nephropathy
• Systemic symptoms


  • Fever
  • Fatigue
  • Weight loss
  • Lymphadenopathy
• Ocular manifestations


  • Sjogren's syndrome
  • Scleritis
  • Episcleritis
  • Scleromalacia
• Pulmonary manifestations


  • Pleural effusion
  • Nodules
  • Fibrosis
  • Caplan syndrome: rheumatoid pneumoconiosis
• Hematological manifestations


  • Anemia (may be due to chronic disease, NSAID use à GI bleed, hemolysis, hypersplenism)
  • Felty's syndrome: RA, splenomegaly, neutropenia
• CBC


  • Normocytic anemia
  • Thrombocytosis
• ESR & CRP


  • Elevated, proportional to inflammatory activity (unlike SLE)
• Rh factor


  IgM autoantibody against Fc part of IgG, positive in 70% of patients, sensitive but not specific
• Anti-CCP


  Anticitrullinated peptide antibody, 95% specific & 80% sensitive
• Seropositivity


  • 70% of cases, more severe, more likely to be erosive, more likely to have extraarticular features, more aggressive treatment
  • 30% of cases are seronegative
• Joint x-ray (early)


  • Soft tissue swelling, marginal erosions
• Joint x-ray


  • Joint narrowing, erosions at joint margins, porosis of periarticular bone (periarticular osteopenia), cysts
• Synovial fluid


  Sterile, high neutrophils
• Diagnostic criteria for inflammatory arthritis

  • Inflammatory arthritis of ≥3 joints
  • Duration >6 weeks
  • Positive RF or anti-CCP
  • High CRP or ESR
• Cure


  No cure; goal is remission, function, maintenance
• Treatment for RA


  1. Start on a disease-modifying agent (DMARD) as soon as possible

  2. Used early to decrease inflammation and slow development of erosion
• Sulfasalazine


  • Drug of choice (DOC) in mild to moderate, young, women
• Methotrexate


  • Drug of choice (DOC) in more active disease
  • Contraindicated in pregnancy & 3 months prior to conception in men & women
• Biological DMARD: Anti-TNFa (infliximab)

  • First line, used in patients with active disease despite treatment with 2 DMARDs including methotrexate
• Flare ups/flare up on diagnosis

  1. Start both a DMARD and an oral steroid

  2. Oral steroids are used short term as bridge therapy to rapidly achieve control on inflammation

  3. Fast onset, ↓ erosions & pain

  4. Tapered when the DMARDs start working

  5. Used in flare ups/relapses but do not slow progression
• NSIADs


  • Best initial therapy for pain
  • Work immediately to relieve pain and stiffness but do not slow progression
• Local injection with a long-acting steroid

  1. May be used in a troublesome joint

  2. Improves pain, but repeated injections should be avoided (accelerate damage)