RHEUMATOID ARTHRITIS

Definition
• Chronic inflammatory disease
• Prolong clinical course of joint swelling and pain  excacerbation
and remission
• Characterized
• joint swelling
• joint tenderness
• destruction of synovial joints
• Leading to severe disability
 Epidemiology

• Affects 2.5 x women as men

• 1.5% of population

• Peak period  20 – 40 years

 Etiology

• Unknown
• Probable background genetic susceptibility  MHC on
chromosome 6 persistent antigen
• Environmental triggers
• Autoimmune disease  rheumatoid factor
Stages of pathology
 RA is Characterised by Synovitis and
Joint Destruction
NORMAL RA
Synovial
membrane Inflamed
synovial
membrane

Major cell types:

•T lymphocytes
•macrophages
Pannus
Cartilage Minor cell types:
•fibroblasts
•plasma cells
•endothelium
•dendritic cells

Synovial
Capsule fluid Major cell type:
•neutrophils

Cartilage thinning
 History
• Insidious onset

• Morning stiffness

• Tiredness, weight loss, malaise

• A functional / cosmetic

• A social history: multiple operations if required

 Clinical Features
1. Early stages

2. Later stage

3. Extra-articular features
 Early Stages
• Typically, woman of 30 – 40 years, complain of pain, swelling
and loss of mobility in the proximal joints of the fingers
• Symptom start spread
• Generalized stiffness after periods of inactivity : bed in early
morning
 Early Stages
• Symmetrically distributed swelling and tenderness of the MCP
joints, the PIP joints and the wrists
• Tenosynovitis wrist
• Test : passively move the fingers
• No joint deformity yet
 Later Stages

• Joint deformity
• Synovitis : the more constant ache of progressive joint destruction
• Joints movement are restricted and often very painful
 Later Stages
• Combination of joint instability and tendon rupture produces the
typical ‘rheumatoid’ deformities
• Ulnar deviation of the fingers
• Valgus knees
• Valgus feet
• Clawed toes
Clinical Finding
 Extra-Articular Features
• Severe disease

• Most characteristic is the appearance of nodules

• Rheumatoid nodules are pathognomotic for RA, but occurs in

only 25% of patients
 Cervical spine
• The commonest form of instability is atlanto-axial
• Atlanto-axial instability  myelopathy, high rate of mortality
• Basilar invagination  most dangerous manifestation  cause brainstem
compression, unstable blood pressure, arrhythmias and sudden death
• Subaxial instability  10-20% of patients and may occur at multiple levels
producing a step ladder type of deformity
 Thoracic and Lumbal
• Less Thoracic and lumbal involvement
 Shoulder
• 90% of RA : glenohumeral or
AC joints
 Elbow
• Mostly bilateral
• Rheumatoid nodules
• Posterior subluxation of the
ulna
 Hip
• Less frequent
 Knees
• The classic deformity : progressive
valgus.
Feet
The forefoot 90% of
patients : hallux valgus
RA is a Systemic Disease

• Rheumatoid Nodules
• Interstitial Lung Disease
• Vasculitits
• Ocular Disease
 RA – Vasculitis
can be life-threatening
Radiology
 Laboratory

• In active phases
• ESR is raised
• C-reactive protein present
• Rheumatoid factor  positive in about 80% of patients
• Anti-citrullinated protein antibodies (ACPAs) or anti-CCP  positive in
only a proportion (67%) RA cases
 Synovial biopsy
• Most of the histological features of rheumatoid arthritis
are non-specific
 Differential Diagnosis
• Systemic lupus erythematosus and other connective tissue
disorders
• Polymyalgia rheumatica
• Seronegative spondyloarthropathies
• Crystal deposition arthritis
• Osteoarthritis
• Infectious arthritis
1987 revised ACR Criteria for RA Diagnosis
4 of the following must be present
• 6 weeks of morning stiffness > 1 hour
• 6 weeks of arthritis affecting PIP, MCP, wrist, elbow knee ankle,
MTP
• 6 weeks of arthritis of wrist, MCP, PIP
• 6 weeks of symmetric involvement of joints
• Rheumatoid nodules
• Positive serum rheumatoid factor
• Radiographic changes including erosions
NEW CRITERIA
 Treatment
• There is no known cure for rheumatoid arthritis

• Alleviate symptoms

• Modify the disease process

 Treatment
• Goal
1. Stop the synovitis
2. Prevent deformity
3. Reconstruct
4. Rehabilitate
• Multidiscipline approach
 Prognosis
• Difficult to predict
• Could be bad:
• High titres of rheumatoid factor
• Periarticular erosions
• Rheumatoid nodules
• Severe muscle wasting
• Joint contractures,
• Vasculitis
 Prognosis
• 10%  improve steadily

• 60%  intermittent phases of disease activity and remission

• 20%  severe joint erosion

• 10%  completely disabled

Thank you