Clinical aspects

epidemiology

· affects 3% of population

· M:F = 3:1

· peak onset is age 35-45

onset

· most commonly presents with

· initial malaise, fever and fatigue

· symmetrical pain and swelling in hands, wrists and feet

Presentations

· four possible presentations

1. slowly progressive polyarthritis

· gradually worse over weeks or months

· involves one then another joint

2. episodic polyarthritis

· acute swelling of one joint

· resolves with asymptomatic interval

· intervals become shorter until polyarthritis develops

3. monoarticular or oligoarticular arthritis

· swollen large joint

· polyarthritis develops later

4. fulminating polyarthritis

· more common in elderly

· acute onset with widespread joint involvement

· marked systemic signs

Outcomes

· four possible outcomes

1. short-lived

· 25% have short-lived disease

· no persisting disability

2. mild

· 25% have disease that remits

· mild persisting disability

3. progressive

· 45% have persistent arthropathy with remissions and exacerbations

· variable progressive deformity

4. severe

· 10% have severe progressive disease with gross deformity

· severe disability

Early features

Symptoms

· early morning joint stiffness

· also after prolonged inactivity (‘gelling’)

· joint swelling

· esp. hands (rings tight)

· polyarthralgia

· initially fingers

· then wrists, feet, knees, shoulders

· systemic symptoms

· weight loss

· fever

· malaise and fatigue

Signs

· symmetrical joint swelling

· esp. MCP, PIP and wrists

· joint tenderness on deep palpation

· limited ROM

· tenosynovitis

· flexor sheaths of fingers

· exensor compartments of wrist

· autonomic dysfunction

· hyperhidrosis and palmar erythema

· carpal tunnel syndrome

articular involvement

Shoulder

· stiffness and swelling of glenohumeral joint

· pain from acromioclavicular joint

Elbow

· stiffness and swelling

· ulnar nerve entrapment

Wrist and hand

· wasting of dorsal interossei

· ulnar drift of fingers at MCP joints

· finger deformities

· boutonniere deformity

· swan-neck deformity

· Z-deformity of thumb

· dropped fingers

· extensor tendon rupture (V, IV, III, II)

· dislocation of extensor tendons

· radial nerve palsy

Spine

Cervical

· alantoaxial instability

· anterior subluxation

· basilar invagination

Lumbar

· minimal changes

Hip

· pain and stiffness

· protrusio acetabulae

· avascular necrosis from steroids

Knee

· flexion contracture

· valgus deformity

· instability from cruciate and collateral ligament involvement

· popliteal cyst

Ankle and foot

· pes planovalgus

· posterior tibial and peroneal tendinitis

· subluxation of MTP joints

· cock up deformity of toes

· metatarsalgia

· plantar callosities

· dorsal toe ulcers

· hallux valgus

extra-articular involvement

Rheumatoid nodules

· occur in 20% of patients

· pathognomonic

· associated with IgM rheumatoid factor

· most commonly occur on subcutaneous surface of forearms

· also found in other areas of pressure

· around knee

· back of skull

· bridge of nose with glasses

· over sacrum

· also found

· on flexor tendons of fingers with triggering

· pleura and lung

· larynx and vocal cords

· pericardium and myocardium

· sclera

Ocular

· all present with a red eye

· include

· episcleritis

· seleritis

· scleral nodule

· keratoconjunctivitis sicca

Pulmonary

· rheumatoid nodules

· if associated with pneumoconiosis, called Caplan’s syndrome

· pleurisy with or without an effusion

· diffuse interstitial fibrosis

Cardiac

· pericarditis

· nodules causing

· valvular insufficiency

· conduction defects

Lymphadenopathy

· may affect nodes draining affected joints

· may also affect nodes at a distance

· due to hyperactivity of reticulendothelial system

Neuromuscular

Myopathy

· wasting and weakness from

· myositis from vasculitis

· steroid or antimalarial treatment

Neuropathy

· sensory

· more common in seropositive men with longstanding disease

· stocking distribution

· burning pain with electric shocks and numbness

· motor and sensory

· acute onset

· all four limbs

· wrist or foot drop

Cervical myelopathy

· cord compression from atlantoaxial instability

Entrapment neuropathies

· carpal tunnel syndrome

· ulnar tunnel syndrome

· cubital tunnel syndrome

· tarsal tunnel syndrome

Vasculitis

Obliterative endarteritis

· digital vessels

· nailfold lesions

· cutaneous lesions of pulps

· Raynaud’s phenomemon

Inflammatory vasculitis

· polyneuritis

· skin infarction and ulceration

Anaemia

· picture

· normocytic

· normochromic

· low serum iron

· low total iron binding capacity

· cause poorly understood

Felty’s syndrome

· combination of

· RA

· splenomegaly

· neutropaenia

· other features are

· lymphadenopathy

· skin pigmentation

· chronic leg ulceration

· thrombocytopaenia

· haemolytic anaema

Sjogren’s syndrome

· combination of

· dry eyes (keratoconjunctivitis sicca)

· dry mouth (xerostomia)

· connective tissue disorder (RA in 50%)

investigations

Haematology

· anaemia

· of chronic disease

· blood loss from NSAIDs

· elevated ESR

· usually parallels disease

Serology

Rheumatoid factor

· seen in 80%

· also present in

· Sjogrens syndrome

· SLE

· pulmonary fibrosis

· significance of high titre

· poorer prognosis

· complications more likely (nodules, vasculitis)

Others

· antinuclear factor may be increased

· serum complement may be increased

Radiology

· cardinal features

· soft tissue swelling

· periarticular osteoporosis

· marginal erosions

· joint space narrowing

· deformity

Histology

· synovial biopsy

· usually non-specific chronic inflammation

· ‘consistent with’ rather than ‘diagnostic of’ RA

diagnostic criteria

· diagnosed on clinical criteria

· confirmed by investigations

Diagnostic clinical criteria

· morning stiffness for > 1 hr

· arthritis

· in 3 or more joint areas

· of hand joints

· symmetrical

· rheumatoid nodules

Confirmation

· typical radiographic changes

· serum rheumatoid factor

differential diagnosis

Seronegative spondyloarthropathies

· Reiter’s syndrome

· ankylosing spondylitis

· psoriatic arthritis

· enteropathic arthritis

Crystal arthropathies

· gout

· pseudogout

Connective-tissue diseases

· juvenile chronic arthritis

· SLE

Other

· septic arthritis

· polymyalgia rheumatica

· sarcoidosis