Rheumatoid Arthritis(RA)Rheumatoid Arthritis(RA)

• Rheumatoid arthritis (RA) is a chronic systemic

inflammatory disorder that may affect many tissues

and organs—skin, blood vessels, heart, lungs, and

muscles—but 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.

• 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.

: *Pathophysiology• Unknown antigen stimulates CD4+ T lymphocytes.• Active CD4+ T lymphocytes;

a. stimulates macrophages to release IL1 and TNF.b. Release RANKL which stimulates osteoclasts leading to

bone destruction.• IL-1 and TNF stimulates synovial cells leading to:

a. Synovial cell proliferation and formation of pannaus.b. Production of prostaglandins (pain sensation) and matrix

metalloproteinases that cause cartilage destruction.

* Sequence of events :

• Proliferation of synovial membrane cells with inflammatory cell infiltrate

• Destruction of joints• Disability

* Diagnosis:

1. Clinical manifestations.

2. Investigations.

1. Clinical manifestations1. Clinical manifestations

• Articular manifestations:– Symmetric peripheral polyarthritis–Morning Stiffness >1 hour

• Extra-articular manifestations:

Symmetric peripheral polyarthritis:

• 3 or more Joints for >6 weeks• Small Joints– Hands & feets– Peripheral to Proximal

• Leads to deformity & destruction of Joints.

Morning stiffness:• Morning or after Prolonged Inactivity.

• Bilateral

• > 1 hour.

• Better with movement

• Pain with movement of joint

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

* Extra-articular manifestations:• Myalgia, fatigue, low-grade fever, weight loss,

depression.• Anemia• Rheumatoid nodules• Pleuropericarditis• Neuropathy• Scleritis• Splenomegaly• Vasculitis

Rheumatoid Nodules

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

22 . .InvestigationsInvestigations

1. Arthrocentesis.

2. Arthroscopy.– Evaluate ligamentous & cartilaginous integrity

– Biopsy

Rheumatoid arthritis showing inflammatory cell infiltrate in the synovium

3. Laboratory investigations:

• Rhumatoid Factor:

– Positive in 70-80% of patients.

- - IgM or IgG

- If IgM+ve : more severe disease & poorer outcome.

• Acute Phase reactants:

– ESR, CRP monitoring disease activity

4. Radiology:

• Evaluate disease activity & joint damage.

a. Plain Films.

b.Color Doppler U/S & MRI

Disease SeverityDisease Severity

Mild caseMild case

• Arthralgias• >3 inflamed joints• Mild functional limitation• Minimally elevated ESR & CRP• No erosions/cartilage loss• No extra-articular manifestations.

Moderate caseModerate case

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

Severe caseSevere case

• >20 persistently inflamed joints• Rapid decline in functional capacity• Radiographic evidence of rapid progression of

bony erosions & loss of cartilage• Extra-articular manifestations.

Bad prognostic FeaturesBad prognostic Features

• RF +ve

• Early development of multiple inflamed joints.

• Severe functional limitation

• Lower socioeconomic status & Less education

• Persistent joint inflammation for >12 weeks