Sunday, 21 October 2007

Rheumatoid Arthritis

Rheumatoid Arthritis

Bilateral symmetrical arthropathy involving both hands

Spindling of the fingers due to swelling of the soft tissue at the MCJ and PIJ with sparing of the DIJ

Generalized wasting of the small muscles of the hand with wasting of the thenar and hypothenar eminence

There is deformity. Describe site

Swan neck


Z shaped deformity

There is subluxation at the MCP with ulnar deviation of the fingers

No evidence of sinovitis

No features of carpel tunnel syndrome

No palpable rheumatoid nodules at the elbow

There is marked functional disability of both hands

What is the differential diagnosis?

Psoriatic arthropathy

Infection, bacterial, viral

Still disease



What are the extra articular manifestations?

Occur in 30% of patients with RA


Plural effusion

Plural nodules

Diffuse fibrosing alveolitis

Obstructive bronchiolitis


Nail fold infarct

Cutaneous Vaculitis

Bowel infarction



Aortic regurg


Mononuritis multiplux

Compressive arthropathy

Atlanto axial subluxation






Scleromalasia perforance

Sicca syndrome

Spleen felty syndrome

How to investigate?


Inflammatory markers

Serology RF +ve in 75 %

X ray of the affected joints

Aspiration if effusion is present

What are the causes of anaemia?

Anaemia of chronic disease

IDA secondary to NSAID’s

Haemolytic anaemia

Pancytopenia secondary to felty syndrome

Bone marrow suppression secondary to treatment

What are the x ray finding?

Juxta articular osteoporosis

Loss of joint space

Bony erosion


Soft tissue thickening

What is the line of management?


Control pain & stiffness

Act on cyclooxygenase pathway


Act through cytokines inhibition

Use early if sero +ve in presence of poor prognostic feature


Intra articular inj


TNF inhibitors

What is the side effect of treatment?


GI bleeding

Fluid retension

Interstitial nephritis


Methotrexate hepatotoxicity

Mouth ulcers

Bone marrow suppression


Sulphsalazine rash

Marrow suppression



Etarnecpt blood disorder

Reaction at the site of injection

Infleximab reaction of TB

What are the complications of RA?

Rupture tendon

Joint infection

Ruptured joint

Spinal cord compression


What are the types of presentations?




Chronic persistant

Rapidly progressive

What are the poor prognostic features?

FR +ve

Extra articular feature



Early erosions

Insidious onset

Anaemia of old age

High inflammatory markers

read about RA new NICE guidelines Feb 2009


  1. causes of occular involvement in RA:
    2-sjogren's syndrome
    3-cataract secondary to steriods therapy
    4-retinopathy secondary to chloroquine
    5-extraocular muscle tendon synovitis
    6-extraocular muscle paralysis secondary to penicilamine induced myaethenia
    7-extraocular muscle paralysis secondary to mononuritis multiplex

  2. causes of renal involvement in RA:
    1-acute tubulointerstitial nephritis secondary to NSAIDs
    20renal papillary necrosis secondary to analgesic abuse
    3-renal amyloid
    4-membraneous nephropathy secondary to gold or penicillamine
    5-minimal change glumerulonephritis complicating NSAIDs

  3. cause of respiratory involvement in RA:
    2-pleural effusion
    3-pulmonary fibrosis
    6-pulmonary nodules
    7-Caplan's syndrome

  4. treatment:
    It is now well established that early intensive intervention with combination therapy at the outset improves outcomes in RA. National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2009) regarding the management of RA state:

    “In people with newly diagnosed active RA, offer a combination of disease-modifying anti-rheumatic drugs (DMARDs) (including methotrexate and at least one other DMARD, plus short term glucocorticoids) as first-line treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms.

    In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate, start DMARD monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the choice of DMARD”

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