Rheumatoid Arthritis(RA)

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Rheumatoid Arthritis(RA)

• Dr. Gehan Mohamed Dr. Abdelaty Shawky

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• Rheumatoid arthritis (RA) is a chronic systemic
  inflammatory disorder that may affect many
  tissues and organsskin, blood vessels, heart,
  lungs, and musclesbut principally attacks the
  joints, producing a non-suppurative proliferative
  and inflammatory synovitis that often progresses
  to destruction of the articular cartilage and
  ankylosis of the joints.

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• Although the cause of RA remains unknown,
  autoimmunity plays a pivotal role in its
  chronicity and progression.
• About 1 of the world's population is afflicted
  by RA, women two to three times more often than
  men. It is most common in those age 40 to 70, but
  no age is immune.

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Pathophysiology

• Unknown antigen stimulates CD4 T lymphocytes.
• Active CD4 T lymphocytes
• stimulates macrophages to release IL1 and TNF.
• Release RANKL which stimulates osteoclasts
  leading to bone destruction.
• IL-1 and TNF stimulates synovial cells leading
  to
• Synovial cell proliferation and formation of
  pannaus.
• Production of prostaglandins (pain sensation) and
  matrix metalloproteinases that cause cartilage
  destruction.

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Sequence of events

• Proliferation of synovial membrane cells with
  inflammatory cell infiltrate
• Destruction of joints
• Disability

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Diagnosis1. Clinical manifestations.2.
Investigations.
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1. Clinical manifestations
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• Articular manifestations
• Symmetric peripheral polyarthritis
• Morning Stiffness gt1 hour
• Extra-articular manifestations

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Symmetric peripheral polyarthritis

• 3 or more Joints for gt6 weeks
• Small Joints
• Hands feets
• Peripheral to Proximal
• Leads to deformity destruction of Joints.

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Morning stiffness

• Morning or after Prolonged Inactivity.
• Bilateral
• gt 1 hour.
• Better with movement
• Pain with movement of joint

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Physical Examination

• Decreased grip strength
• Carpal tunnel syndrome(condition characterized by
  pain and numbing or tingling sensations in the
  hand and caused by compression of a nerve in the
  carpal tunnel at the wrist.
• Ulnar deviation

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Extra-articular manifestations

• Myalgia, fatigue, low-grade fever, weight loss,
  depression.
• Anemia
• Rheumatoid nodules
• Pleuropericarditis
• Neuropathy
• Scleritis
• Splenomegaly
• Vasculitis

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Rheumatoid Nodules

• Extensor surfaces especially elbows
• Very Specific
• Only occur in 30
• Late in Disease

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2. Investigations
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• 1. Arthrocentesis.
• 2. Arthroscopy.
• Evaluate ligamentous cartilaginous integrity
• Biopsy

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Rheumatoid arthritis showing inflammatory cell
infiltrate in the synovium
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3. Laboratory investigations

• Rhumatoid Factor
• Positive in 70-80 of patients.
• - - IgM or IgG
• - If IgMve more severe disease poorer
  outcome.
• Acute Phase reactants
• ESR, CRP ? monitoring disease activity

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4. Radiology

• Evaluate disease activity joint damage.
• Plain Films.
• Color Doppler U/S MRI

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Disease Severity
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Mild case

• Arthralgias
• gt3 inflamed joints
• Mild functional limitation
• Minimally elevated ESR CRP
• No erosions/cartilage loss
• No extra-articular manifestations.

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Moderate case

• 6-20 Inflamed joints
• Moderate functional limitation
• Elevated ESR/CRP
• Radiographic evidence of inflammation
• No extra-articular manifestations.

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Severe case

• gt20 persistently inflamed joints
• Rapid decline in functional capacity
• Radiographic evidence of rapid progression of
  bony erosions loss of cartilage
• Extra-articular manifestations.

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Bad prognostic Features

• RF ve
• Early development of multiple inflamed joints.
• Severe functional limitation
• Lower socioeconomic status Less education
• Persistent joint inflammation for gt12 weeks

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