Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It typically presents with symmetric joint pain and stiffness, especially in the hands and feet. Investigations may show elevated inflammatory markers, rheumatoid factor, anti-CCP antibodies, and erosive changes on x-ray. Treatment involves NSAIDs, corticosteroids, and disease-modifying anti-rheumatic drugs like methotrexate which reduce symptoms and progression. Surgical options are considered for joint damage.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It typically presents with symmetric joint pain and stiffness, especially in the hands and feet. Investigations may show elevated inflammatory markers, rheumatoid factor, anti-CCP antibodies, and erosive changes on x-ray. Treatment involves NSAIDs, corticosteroids, and disease-modifying anti-rheumatic drugs like methotrexate which reduce symptoms and progression. Surgical options are considered for joint damage.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It typically presents with symmetric joint pain and stiffness, especially in the hands and feet. Investigations may show elevated inflammatory markers, rheumatoid factor, anti-CCP antibodies, and erosive changes on x-ray. Treatment involves NSAIDs, corticosteroids, and disease-modifying anti-rheumatic drugs like methotrexate which reduce symptoms and progression. Surgical options are considered for joint damage.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It typically presents with symmetric joint pain and stiffness, especially in the hands and feet. Investigations may show elevated inflammatory markers, rheumatoid factor, anti-CCP antibodies, and erosive changes on x-ray. Treatment involves NSAIDs, corticosteroids, and disease-modifying anti-rheumatic drugs like methotrexate which reduce symptoms and progression. Surgical options are considered for joint damage.
Rheumatoid Arthritis Dr. RANA ATEF KHASHABA Table of contents Definition and Pathogenesis 01 Risk factors 02
Investigations 03 Clinical picture 04
05 Treatment 01 Definition and Risk factors Definition and Risk factors ❑ It is a Chronic, systemic auto immune disease causing symmetrical, erosive synovitis of multiple joints (mainly of hands & feet) with extra-articular features. ❑ Prevalence: 1% of population Female : Male ratio = 3:1 ❑ Aetiology: Unknown, ❑ Risk factors: ✓ Genetic predisposition: Inheritance of HLA-DRB1 alleles encoding a distinctive five-amino-acid sequence known as the “shared epitope” is the best characterized genetic risk factor. ✓ Infection: viral (EBV) 02 Pathogenesis Pathogenesis: The most accepted theory: (autoimmune disease)
• Initiating event (?? viral infection) • The immune complex fixes the complement stimulates susceptible T cells → and engulfed by PNL cells which initiate release of lymphokines (IL1, IL6 & synovitis. TNF)→ stimulation of B & T cells proliferation. • Repeated autoimmune inflammation →the following: ❑ Angiogenesis (with small-vessel vasculitis) ❑ Accumulation of inflammatory cells in the • The B cells release IgG (usually synovium (nodules formation) abnormal), the immune system ❑ Synovial cell proliferation (rapidly growing releases IgM (RF) against the pannus)→ erosion of articular cartilages & formed IgG. Both antibodies bond subchondral bone of joint space → Fibrosis & together to form immune complex. joint deformity RANKL/RANK signaling regulates osteoclast formation, activation and survival in normal bone modeling and remodeling and in a variety of pathologic conditions characterized by increased bone turnover 3 Clinical picture Articular manifestations Extra-articular manifestations Special types of rheumatoid arthritis Diagnostic Criteria of RA Clinical picture • Age of onset: 20-40 years in females, 50-70 years in males • General symptoms: Fever, headache, malaise, anorexia, loss of weight, palmar erythema • Articular manifestations: 1- Symmetrical polyarthritis (the most important) • The joint becomes swollen, red, hot & tender with limitation of movements • Morning stiffness for > 30-60 minutes, partially relieved by movements. • Affecting mainly small distal joints of hands & feet • Wrist, MCP & PIP joints are the most commonly affected 2- Joint deformity: Late, due to erosion and destruction of the joint • Ulnar deviation: fingers deviated toward the little finger. • Boutonniere deformity: hyperflexion at PIP joint with hyperextension at DIP • Swan neck deformity: hyperextension at PIP joint, hyperflexion at DIP. • Z-shaped thumb: fixed flexion at the MCP joint and hyperextension at the IP joint 3- Complications: • Disability and disuse atrophy: due to joint deformity • Tenosynovitis • Ruptured Baker's cyst (outpouching of synovium behind the knee) Early rheumatoid arthritis
Subcutaneous nodules:20% of patients have
subcutaneous rheumatoid nodules ,most commonly situated over bony prominences but also observed in the bursae and tendon sheaths . Nodules are occasionally seen in the lungs, the sclerae, and other tissues. Late Rheumatoid arthritis A: Early changes: symmetric swelling of MCP & PIP joints B: Ulnar deviation of the fingers C: Boutonnière deformity D: Subcutaneous rheumatoid nodules around the joints. E: Swan-neck deformity of the little finger. Extra-articular manifestations: 1- C.V.S: Pericarditis, myocarditis, endocarditis, HTN, IHDs. 2- Chest: Pleurisy - interstitial pulmonary fibrosis, pulmonary HTN, Caplan's syndrome (rheumatoid nodules in the lung)
4- Nervous system: • Neuropathy, Epilepsy • Carpal tunnel syndrome: median nerve compression due to hypertrophied synovium • Spinal cord compression: due to atlanto-axial joint sublaxation (incomplete dislocation between C1 and C2 5- Skin: • Subcutaneous nodules: formed over extensor surfaces of the limbs (usually over bony prominences) 6- Eye: Conjunctivitis, Scleritis (blue sclera) 7- Blood: Aneamia of chronic disease ● Special types of rheumatoid arthritis 1- Sjogran syndrome: Rheumatoid arthritis, lymphadenopathy Dry eye (xerophthalmia): scleritis, peripheral ulcerative keratitis dry mouth (xerostomia) There is increased incidence of lymphoma
2- Felty's syndrome: Rheumatoid Arthritis Hepatosplenomegaly Lymphadenopathy Pancytopenia (mainly neutropenia) as a result of splenomegaly
3- Still disease: Mainly in children Arthritis, fever, splenomegaly & skin rash ● Diagnostic Criteria of RA (American Rheumatism Association,1987):
4 or more of the following for > 6 weeks
1. Morning stiffness (> 1 hour)
2. Swelling of 3 or more joint areas 3. Arthritis in at least 1 of : MCP, PIP or wrist 4. Symmetric arthritis 5. Rheumatoid nodules 6. Positive serum RF 7. X-ray changes: Periarticular erosions or osteopenia ● D.D Osteoarthritis: (Degenrative joint disease) 1. No constitutional manifestations. 2. joint pain is relieved by rest. 3. Common in old age Gouty osteoarthritis: 1. Intermittent and monoarticular in the early years. 2. With time it become chronic polyarticular process that mimics rheumatoid arthritis but are not associated with rheumatoid factor 3. Presence of synovial urate crystals 4. Gouty tophi can resemble rheumatoid nodules but are not associated with rheumatoid factor. SLE: • RA causes severe joint inflammation and deformity with mild extra-articular features • SLE Mild joint ( articular) manifestations with severe ( fatal) extra articular manifestations with Malar rash, photosensitivity, discoid skin lesions, alopecia, high titer anti ds DNA Or anti Smith Investigations 4 Plain X-ray hand or foot Serological tests Arthrocentesis Blood Investigations 1- Plain X-ray hand or foot: first 6 months of symptoms are usually normal Osteoporosis (Decreased bone denisty) Periarticular bone erosions Narrow joint space 2- Serological tests: Rheumatoid factor (RF): It is IgM directed against Fc of IgG Positive in 80-90 % of cases Non specific for RA but usually used for follow up & severity evaluation Anti-nuclear antibody (ANA): positive in 20% of cases Anti-cyclic citrullinated peptide (anti CCP): The best & most specific test for diagnosis of RA. 3- Arthrocentesis: aspiration of synovial fluid from the joint 4- Blood: WBCs is normal or slightly elevated, but leukopenia may occur, often in the presence of splenomegaly (eg, Felty syndrome). anemia, ESR > 100, high C-reactive protein. Osteopenia Narrow joint space
Ulnar deviation 5 Treatment ❑ General treatment ❑ Medical treatment NSAIDs Corticosteroids DMARDs ❑ Surgical treatment 1-General treatment: rest, joint splinting, physiotherapy 2- Medical treatment: • NSAIDs: for relive of pain e.g: Aspirin, Diclofenac, Indomethacin, Ketoprofen
• Small-dose Corticosteroids: prednisone 5-10
mg/day, has anti-inflammatory effects & may decrease disease progression till the effects of DMARDs take place. • Disease modifying anti-rheumatic drugs (DMARDs): The best treatment for RA Reduce activity & delay progression of the disease as they increase T cell sensitivity to apoptosis, so they decrease the immune response. They are slow-acting drugs (their effect take 4-8 weeks to appear). ❑ Synthetic DMARDs: a. Methotrexate: The best initial DMARD for RA patients Dose: 7.5 mg/week orally Its beneficial effects appear after 2-6 weeks b. Sulfasalazine: 500-3000 mg/day orally. It is contraindicated in patients with G6PD deficiency c. Leflunomide (Avara): 20 mg/day. It is teratogenic. d. Hydroxychloroquine: 200-400 mg/day orally. It is best used in combination with methotreaxate & sulfasalazine. Retinal toxicity & visual loss . ❑ Biological DMARDs: in severe RA • Tumor necrosis factor-α (TNF-α) blockers:- e.g.: Infliximab, Adalimumab, etanercept • Interleukin – 1 blocker: Anakinra • The best method for RA treatment is DMARDs combination therapy e.g: (Methotrexate plus Infliximab) Or (Methotrexate plus sulfasalkazine plus hydroxychloroquine)
3- Surgical treatment: Synovectomy Joint replacement • Usually insidious onset with morning stiffness and joint pain. • Symmetric polyarthritis with predilection for small joints of the hands and feet; deformities common with progressive disease. • Radiographic findings: joint erosions, and joint space narrowing. • Rheumatoid factor and antibodies to cyclic citrullinated peptides (anti-CCP) are present in 70– 80%. • Extra-articular manifestations: subcutaneous nodules, interstitial lung disease, pleural effusion, pericarditis, splenomegaly with leukopenia, scleritis, and vasculitis THANK YOU
