Rheumatoid Arthritis

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Rheumatoid Arthritis

• Dr John Axford
• Academic Unit for
• Musculoskeletal Disease
• St. George's Hospital Medical School, London

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Rheumatoid Arthritis

• Most Common and Disabling Autoimmune Arthritis
• Multi-system
• Immunological abnormalities
• Symmetrical joint inflammation
• Extra-articular complications

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Rheumatoid Arthritis

• Epidemiology
• Prevalence 1-3 of UK population
• Age Increases with age peaks between 30-55
• Sex Pre-menopausal women 3 x more susceptible
• Race Increased incidence Pima Indians, Afro
  Caribbean, Asian

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Rheumatoid Arthritis

• Epidemiology continued
• Genetics MHC Class II
• Monozygotic twin concordance - 20
• Geography Increased incidence urban versus rural
  communities

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Rheumatoid Arthritis

• Aetiology
• Exact cause(s) unknown
• Initial insult(s)
• Perpetuation of autoreactive immune response
• Environmental
• M. tuberculosis
• Mycoplasma
• EBV
• Retroviruses

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Rheumatoid Arthritis

• Aetiology continued
• Genetic
• HLA DR4
• 70 of Caucasians seropositive RA
• 15 healthy population
• DRB0401 and 0404 disease associated in
  Caucasians
• Shared epitope hypothesis

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Rheumatoid Arthritis

• Pathogenesis and Pathology
• Erosion of bone and cartilage
• Synovial hypertrophy
• B cellsRheumatoid factor production
• T lymphocytes CD4 positive
• Mononuclear cells
• Polymorphonuclear leukocytes

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Rheumatoid Arthritis

• Pathogenesis Pathology
• Rheumatoid factor
• Antibody against Fc fragment of IgG
• 75 of patients with RA
• Immune complexes activate complement
• Participate in inflammatory response

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Rheumatoid Arthritis

• Clinical Features
• Systemic 70
• Weeks/months before onset of arthritis
• Lethargy
• Anorexia
• Weight loss
• Mild Pyrexia

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Rheumatoid Arthritis

• Musculoskeletal
• Joints
• Pain, exacerbated by movement
• Swelling
• Stiffness, most severe on waking
• Deformity
• Popliteal cysts
• Inflamed bursae

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Rheumatoid Arthritis Disease Pattern

• Progression is variable
• Onset rapid or insidious
• Initially single or multiple joints
• Exacerbations and remissions
• Season and climate may have an affect

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Rheumatoid Arthritis Disease Pattern

• Patterns
• Palindromic RA, repeated brief attacks affecting
  one joint
• One episode of polyarthralgia
• Relapse and remission with joint damage

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Rheumatoid Arthritis

• Hand changes in RA
• Spindle-shaped deformity
• Muscle atrophy
• Ulnar deviation of the fingers
• Extensor tendon subluxation or rupture

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Rheumatoid Arthritis

• Hand changes in RA
• Finger Deformities
• Swan neck and Boutonniere deformity
• flexion at the PIP joint and hyperextension at
  the DIP joint)
• Z-shaped deformity
• palmar subluxation of the proximal phalanges
• flexion at the MCP joint

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Rheumatoid Arthritis

• Foot changes in RA
• Eversion of the foot (subtalar joint)
• Forefoot widening
• Lateral deviation and dorsal subluxation of the
  toes
• Metatarsophalangeal joint subluxation

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Rheumatoid Arthritis

• Nervous System
• Central nerve and root compression
• Vasculitis
• Sensorimotor neuropathy
• Atlantoaxial subluxation
• Cervical myelopathy

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Rheumatoid Arthritis

• Eyes
• Sjögrens syndrome - 5 to 20
• Scleritis
• Scleromalacia perforans
• Corticosteroidscataract
• Bones and muscles
• Muscle weakness
• Osteoporosis

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Rheumatoid Arthritis

• Immunological
• Lymphadenopathy
• Amyloidosis
• Haematological
• Anaemia
• Skin
• Rheumatoid nodules
• Vasculitis

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Rheumatoid Arthritis

• Heart
• Acute Pericarditis
• Endocarditis
• Myocarditis
• Myocardial Infarction

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Rheumatoid Arthritis

• Lungs
• Pleuritis
• Obliterative bronchiolitis
• Pulmonary nodules
• Interstitial fibrosis

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Rheumatoid Arthritis

• Feltys Syndrome
• 1 of Patients
• Synovitis severe
• Rheumatoid factor positive
• Splenomegaly
• Neutropenia
• Extra Articular Features
• weight loss, leg ulcers, infections

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Rheumatoid Arthritis

• To Make a Diagnosis
• History
• Examination
• symmetrical arthritis, rheumatoid nodules
• Investigations
• Rheumatoid Factor
• Radiography

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Rheumatoid Arthritis

• Prognosis
• 5-10 severe disease
• 70 persistent arthritis
• Poor outcome
• Systemic manifestations
• Raised RF
• Subcutaneous nodules
• Early joint erosions