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Updated: Apr 30 2022

Rheumatoid Arthritis

Images neck deformity.jpg
  • Snapshot
    • A 36-year-old woman presents to her physician's clinic with pain and swelling in the hands and wrists. She reports morning stiffness that lasts for approximately 1 hour which later improves. She also states to be experiencing symptoms of depression and fatigue. On physican exam, there is decreased grip strength and 4/5 strength on wrist extension. There is tenderness to palpation and swelling of the proximal interphalangeal joints and metacarpophalangeal joints.
  • Introduction
    • Definition
      • a chronic autoimmune disorder that primarily affects the joints and results in an inflammatory synovitis
    • Epidemiology
      • demographics
        • sex
          • more common in women
        • age
          • 30-50 years of age
      • risk factors
        • smoking
    • Etiology
      • environmental and genetic factors play a role
    • Pathogenesis
      • T- and B-cell response after a triggering event (e.g., infection in a genetically susceptible patient) eventually results in
        • pannus formation and subsequent damage to the adjacent cartilage and bone
          • Th1 cells release interferon-γ (IFN-γ) in order to activate macrophages and synovial cells
          • Th17 cells secrete interleukin-17 (IL-17) in order to recruit monocytes and neutrophils
          • synovial plasma cells produce antibodies against self antigens such as citrullinated peptides
    • Genetics
      • HLA-DR4
    • Associated conditions
      • Sjogren syndrome
      • Felty syndrome
        • seropositive rheumatoid arthritis with neutropenia
          • many patients have splenomegaly
      • Caplan syndrome
        • seropositive rheumatoid arthritis with pneumoconiosis
    • Prognosis
      • certain patients with early rheumatoid arthritis may achieve remission
  • Presentation
    • Symptoms
      • fatigue and depression
      • morning stiffness that lasts > 1 hour
      • pain, stiffness, and/or swelling of the joint such as the
        • metacarpophalangeal (MCP) joints
        • proximal interphalangeal (PIP) joints
        • metatarsophalangeal (MTP) joints
    • Physical exam
      • anemia of chronic disease
      • weight loss
      • decreased grip strength
      • palmar erythema
      • subcutaneous (rheumatoid) nodules
      • splenomegaly in cases of Felty syndrome
      • ulnar deviation of the fingers
      • swan neck deformity
      • bouttoniere deformities
  • Imaging
    • Radiography
      • indications
        • can be obtained during the initial workup to have a baseline to compare to when following disease progression
        • can be performed of the neck to rule out odontoid ligament laxity
      • modality
        • hands, wrists, and feet
      • findings
        • diffuse osteopenia
        • joint space narrowing in the carpal, metacarpal, phalangeal, and interphalangeal joints
        • periarticular bony erosions
        • ulnar deviation of the fingers
  • Studies
    • Labs
      • rheumatoid factor (RF) antibody testing
        • RF is an IgM antibody that targets the Fc portion of IgG
      • anti-CCP antibody testing
        • more specific for rheumatoid arthritis
      • erythrocyte sedimentation rate (ESR) levels
        • typically elevated
        • caused by interleukin 1, interleukin 6, and tumor necrosis factor alpha
      • C-reactive protein (CRP) levels
        • typically elevated
    • Diagnostic criteria
      • diagnosis is based on clinical presentation and laboratory studies
  • Differential
    • Systemic lupus erythematous
    • Psoriatic arthritis
    • Scleroderma
    • Polymyalgia rheumatica
    • Gout
  • Treatment
    • Conservative
      • education, exercise, physical therapy, vaccinations, smoking cessation, and counseling
        • indication
          • a component of treatment for patients with rheumatoid arthritis
    • Pharmacologic
      • disease-modifying antirheumatic drugs (DMARDs)
        • indications
          • used to prevent, stop, or retard disease-associated damage
        • medications
          • methotrexate
            • typically the initial DMARD used
          • tumor necrosis factor (TNF) inhibitor such as
            • etanercept
            • adalimumab
          • leflunomide
          • sulfasalazine
          • hydroxychloroquine
      • nonsteroidal antiinflammatory drugs (NSAIDs) and/or glucocorticoids
        • indications
          • initially given for symptomatic control while waiting for DMARD response
    • Operative
      • joint replacement surgery
        • indication
          • in patients with severe joint damage or failure to respond to conservative and medical therapy
  • Complications
    • Hand deformities
    • Atlantoaxial subluxation
    • Popliteal cyst
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