Updated: 4/30/2022

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
      • 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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