Rheumatoid arthritis (RA)

RA is a chronic systemic inflammatory

disease, characterized by a symmetrical,
deforming, peripheral polyarthritis.
 Presentation
Typically: Symmetrical swollen, painful, and stiff
small joints of hands
and feet, worse in the morning. (larger joints
may become involved).
Less common presentations:
•Sudden onset, widespread arthritis.
•Recurring mono/polyarthritis (palindromic RA).
•Persistent monoarthritis (knee, shoulder, or hip).
•Systemic illness with extra-articular symptoms, eg fatigue,
fever, weight loss, pericarditis, and pleurisy, but initially
few joint problems
•Polymyalgic onset .
•Recurrent soft tissue problems (eg frozen shoulder, carpal
tunnel syndrome ).
 Signs
Early: (Inflammation, no joint damage.) Swollen
MCP, PIP, wrist, or MTP joints (often symmetrical)
(tenosynovitis ).
Later: (Joint damage, deformity) Ulnar deviation
and subluxation of the wrist and fingers.
Boutonniere and swan-neck deformities of fingers
or Z-deformity of thumbs occur.
Atlanto-axial joint subluxation may threaten the
spinal cord (rare).
Ulnar deviation
Boutonniere
swan-neck
Z-deformity of thumbs
 Extra-articular manifestations
• Nodules: Elbows, lungs, cardiac,
• Lungs: interstitial fibrosis, bronchiolitis obliterans
• Cardiac: IHD, pericarditis, pericardial effusion
• carpal tunnel syndrome
• peripheral neuropathy
• Felty’s syndrome: RA + splenomegaly +
neutropenia
• Eye: Episcleritis, scleritis
• amyloidosis is rare
Nodules: Elbows
 Investigations
Rheumatoid factor (RhF) is positive in ~70% ).
High titres associated with severe disease, erosions,
and extra-articular disease.
Anticyclic citrullinated peptide antibodies (anti-
CCP) are highly specific ( may also predict
disease progression)
Anaemia of chronic disease, high platelets, ESR and
CRP.
X-rays
 Management
Refer early to a rheumatologist (before irreversible destruction).
• Early use of DMARDS and biological agents improves long-term
outcomes
• Steroids rapidly reduce symptoms and inflammation.
• NSAIDS are good for symptom relief, but have no effect on
disease progression.
• physio- and occupational therapy
• Surgery may relieve pain, improve function, and prevent
deformity.
Disease-modifying antirheumatic drugs (DMARDS)
are 1st line and should ideally be started within
3 months of persistent symptoms.
Best results are often achieved with a
combination of methotrexate, sulfasalazine, and
hydroxychloroquine.
SE: pancytopenia, susceptibility to
infection (including atypical organisms), and
neutropenic sepsis