Rheumatoid Arthritis

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XR

Cartilage

Primary: DIPPIP,hip,kneespine, 1 MTPSecondary:

OA

Synovial fluidXR

Urate level

CartilageSynoviumSoft tissue

Bone

GoutPseudogout

Crystal

RFXR

SynoviumJoints + C-spine

>> Systemic

RA

XRHLA B27

SynoviumEntheses

Axial + peripheraljoints>> systemic

ASPsoriatic

EnteropathicReactive

SpA

ANFENA

Organ Fx tests

SynoviumSystemic >>Synovium

SLEPSS

PM/DMMCTD

CTD

ANCAHistologyImaging

SynoviumSystemic >>Synovium

PAN,WegenersTakayasu,GCA etc

Vasculitis

Arthritis

Rheumatoid arthritis

• Most common form of inflammatory arthritis

• Affects 1 % of all populations

• Females > males 3:1

Rheumatoid Arthritis

• Wide variation in – age at onset– degree of joint involvement– severity of disease

• Difficult to predict early on who will develop more severe disease

Effects of RA

• Systemic disease but joint involvement dominates

• RA affects morbidity and mortality

• RA reduces life expectancy– males by 7 year– females by 3 years

Etiology• Immune mediated chronic inflammation• Trigger: Environmental

AntigenGenetic (30%)Self Antigen

T cell activation

Chronic InflammationLymphoid cells infiltrate synovium

New blood vessels form in synoviumSynovial proliferation

Joint destruction

Mechanisms of joint damage• Synovial mass stretches joint capsule and

ligaments: joint swelling, instability & deformity

• Cytokine and proteolytic enzyme rich synovialfluid destroys cartilage joint space narrowing on X-rays

• Infiltration of cartilage and later bone by invading synovium (pannus) marginal erosions

Onset

• 60% insidious onset of pain, stiffness, symmetrical swelling of joints especially small joints

• 20% acute or subacute• 10% vague aches and pains• 5% systemic symptoms: fatigue,

malaise, weight loss, low fever, myalgia, morning stiffness, depression

ACR Classification Criteria (4/7)

• EMS > 1 hour• > 3 joint arthritis• Symmetrical arthritis• Wrist, MCP, PIP arthritis• Rheumatoid nodules• Rheumatoid factor• X-ray changes: periarticular

osteopaenia/marginal erosions

Articular involvement

Articular involvement

Any synovial joint can be involved

Also inflammation of synovium in bursaeand tendon sheaths

Can start asymmetrically with only few joints affected

Articular involvement

• Spreads within months to years to other joints in symmetrical distribution

• Joint involvement reaches a plateau after first few years

• Number of joints affected in early disease related to severity of disease

Hand• MCP joints

– Synovitis– Ulnar deviation

• PIP joints– Synovitis– Swan neck deformity– Boutonniere deformity

• Z-deformity of thumb • Tendons

– Flexor tenosynovitis– Extensor tenosynovitis

• Poor grip: power and pinch

Wrist

• Synovitis• Piano key sign (distal radio-ulnar joint)• Subluxation• Radial deviation• Ankylosis• Carpal tunnel syndrome

Elbow

• Synovitis• Flexion contracture• Decreased, painful pronation and

supination• Olecranon bursitis• RA nodules

Shoulder

• Subacromial bursitis• Rotator cuff tendinitis• Glenohumeral joint arthritis• Acromio-clavicular arthritis

Foot

• MTP – Synovitis– Subluxation with hammer/claw toe and

metatarsalgia– Bunions– Bunionettes– Toe deviation/overriding

• Collapse of medial arch of foot

Ankle/Hindfoot

• Ankle– Synovitis– Retrocalcaneal bursitis

• Tenosynovitis/rupture– Peroneal tendons– Tibialis posterior

• Subtalar arthritis – Reduced and painful movement – Hindfoot valgus

Knee

• Synovitis• Effusions• Baker’s cyst +/- rupture• Instability/ deformity eg valgus deformity• Flexion contracture

Hip

• Arthritis (usually late)– Pain especially on weight bearing– Reduced movement

• Trochanteric bursitis

Cervical spine

• Involved in 70% patients with longstanding RA

• Occipital pain made worse by movement• Subluxation of C1-2 with compression of

spinal cord during neck flexion– Significant if >10 mm instability on flexion – Usually slowly developing myelopathy

• Subaxial subluxation

Serial cervical X-rays in a RA patient

Other joints

• TMJ: reduced mouth opening

• Sternoclavicular

• Crico-arytenoid

• Ossicles of ears

Non-articular manifestations

Non-articular manifestations

• Generalized lymphadenopathy

• Nodules – 30% patients– external over areas of pressure– internally eg lung, heart, gallbladder– central necrosis with pallisade of

fibroblasts

Non-articular manifestations

• Lungs– Pleurisy– Pleural effusions (NB exudate!)– RA nodules single/multiple (Caplan

syndrome if huge nodules in coal miners)– Lung fibrosis

Non-articular manifestations

• Heart– pericarditis, usually asymptomatic, but can

lead to friction rubs / effusions / tamponade– RA nodules: conduction defects

Non-articular manifestations

• Bone– Generalized osteoporosis

• Muscle– Muscle atrophy– Rarely myositis

Non-articular manifestations

• Skin– Palmar erythaema– Digital gangrene (small arteries)– Nail fold infarcts (small arteries)– Skin ulcers (medium arteries)– Purpuric papules (venules)– Palpable purpura (leukocytoclastic

vasculitis)

Non-articular manifestations

• Eyes– Secondary Sjögren syndrome– Episcleritis– Scleritis– Scleromalacia perforans

Complications

Complications

• Infections– More susceptible to any infection (RA,

steroids, MTX)– ESPECIALLY susceptible to joint

infections

– Always suspect septic arthritis if sudden increase in symptoms in one joint

Complications

• Felty syndrome– Splenomegaly and low WBC in RA

• Neurological– Entrapment neuropathy: CTS, ulnar nerve, tarsal

tunnel syndrome– Mononeuritis multiplex (RA vasculitis)– Atlanto-axial subluxation with cord compression

Complications

• Osteoporosis and fractures– RA– Immobility– Steroids

• Amyloidosis– Rare – Longstanding disease– Proteinuria/decreased renal function

Special investigations

Laboratory diagnosis• Rheumatoid factor

• Raised markers of inflammation (ESR/ CRP)

• LFT abnormalities– Raised ALP– Raised proteins (polyclonal rise in globulins, often

also low albumin)

• FBC abnormalities:– Anaemia of chronic disease– Reactive thrombocytosis

Rheumatoid factor• Antibodies against human IgG Fc

• 1-5% of normal people

• Also in chronic infectionsand inflammation eg TB, endocarditis and liver cirrhosis

Radiological diagnosis

• Periarticular soft tissue swelling• Periarticular osteopaenia• Joint space narrowing• Marginal joint erosions leading eventually to

complete joint destruction• Subchondral cysts• Compressive changes due to collapse of

osteoporotic subchondral bone eg protrusioacetabuli at hip

Serial X-rays of a knee in RA

Treatment

Multidisciplinary Care

• Rheumatologist• Orthopaedic Surgeon• Physiotherapist• Occupational therapist• Orthotist• Psychologist• Community based support systems

– Arthritis Foundation– Patient Partners– Support Groups

Medical Treatment• Greatest and irreversible joint damage

occur early in disease

• Thus: Treat early and aggressively

• No single treatment regimen consistently halts disease progression

Medical Treatment

Symptomatic:NSAID’s, paracetamol, opioids, low dose steroids, atypical analgesics

Intra-articular steroids

Disease modifiers: Slow acting and side effects!Methotrexate, Chloroquine, Sulphasalazine, D-penicillamine, gold salts, leflunomide, high doses steroids, immunosuppressants, biologicals (anti TNF alpha and IL-1 agents)

Surgical Treatment

• Soft tissue:– Carpal tunnel release– Synovectomy– Tendon transfers

• Joint replacement• Arthodesis• Excision arthroplasty eg radial head

Treatment

• Rest vs exercise

• Diet– Avoid obesity– “Anti-inflammatory diet”: vegetarian with

omega 3 fatty acids (fatty fish/fish oils)– Essential fatty acids (evening primrose oil)– Anti-oxidants?