Updated: 2/18/2020

Rheumatoid Arthritis

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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
    • 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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(M1.MK.15.4666) A 35-year-old woman presents with a 4-month history of hand pain that is worse when awakening in the morning. She reports that her pain improves throughout the morning. Both hands are equally affected. Findings from a physical examination are shown in Figure A. Which of the following autoantibodies is highly specific for this patient's disorder? Tested Concept

QID: 107096
FIGURES:
1

Anti-Smith antibodies

0%

(0/22)

2

Antihistone antibodies

0%

(0/22)

3

Anticentromere antibodies

5%

(1/22)

4

Anti-IgG antibodies

0%

(0/22)

5

Anti-citrullinated protein antibodies

91%

(20/22)

M 1 A

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(M1.MK.13.15) A 38-year-old female visits your office complaining of several years of joint swelling and stiffness that is worse in the morning and improves throughout the day. Physical examination reveals bilateral deformities at her proximal interphalangeal and metacarpophalangeal joints. The presence of which of the following in this patient’s serum would most help 'rule in' a diagnosis of rheumatoid arthritis: Tested Concept

QID: 100436
1

Rheumatoid factor

15%

(26/168)

2

Anti-nuclear antibody

6%

(10/168)

3

Anti-citrullinated protein antibody

74%

(124/168)

4

Anti-centromere antibody

3%

(5/168)

5

Anti-smooth muscle antibody

0%

(0/168)

M 2 D

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Evidence (6)
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Topic COMMENTS (19)
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