Rheumatoid Arthritis
Clinical Features
- Typically insiduous onset
- Most commonly presents with
- Morning stiffness
- Malaise
- Fatigue
- Fever
- Weight loss
- Symptoms pain & swelling in hands/ wrists/ feet
- 10% have abrupt onset with systemic signs
- Fever
- Chills
- Rash
- Adenopathy
- Splenomegaly
- Visceral involvement
- Stills Disease
- May precede the articular manifestations
- Hands/ wrists, elbows, shoulders, knees, ankles & neck often involved
- hip & DIPJ rarely involved
- Four Presentations
- Slowly Progressive Polyarthritis
- Gradually worse over months
- Involves one then another joint
- Episodic Polyarthritis
- Acute swelling of one joint
- Resolves with asymptomatic interval
- Intervals shorter until polyarthritis develops
- Monoarticular or Oligoarticular Arthritis
- Swollen large joint
- Polyarthritis develops later
- Fulminating Polyarthritis
- More common in elderly
- Acute onset with widespread joint involvement
- Marked systemic signs
- Four Outcomes
- Short-lived
- 25%
- No disability
- Mild
- 25%
- Mild disability
- Progressive
- 40%
- Variable progressive deformity
- Severe
- 10%
- Gross deformity
- Severe disability
- Rapid progressive
- Really 2 subgroups » those that…
- Do well
- Do REALLY BADLY
- Early Features
- Symptoms
- Early morning joint stiffness
- Stiff after rest
- Joint swelling
- Especially hands
- Polyarthralgia
- Initially fingers
- Then wrists, feet, knees & GHJ
- Systemic symptoms
- Weight loss
- Fever
- Malaise
- Signs
- Symmetrical joint swelling & pain
- Especially MCPJ/ PIPJ/ wrist
- Joint tenderness on deep palpation
- Limited ROM
- Tenosynovitis
- Flexor tendon sheaths of fingers
- Extensor compartments of wrists
- Autonomic dysfunction
- Hyperhidrosis
- Palmar Erythema
- Nerve entrapment
- CTS
- Telangiectasia
- Eye involvement
Articular Disease
- Hands
- Early see PIPJ swelling from synovitis
- Bilateral MCPJ symmetrical swelling
- Fingers ulnar deviate & MCPJ sublux
- Swan Neck & Boutonierre deformities
- Z deformity of the thumb
- Extensor tendon rupture
- Causes of dropped fingers in rheumatoid include
- MCPJ subluxation
- Ulnar subluxation of tendons
- Extensor rupture
- PIN palsy
- Trigger finger
- Wrists
- Active extensor synovitis
- CTS secondary to flexor synovitis
- DRUJ involvement with Caput Ulnae syndrome
- Wrist ankylosis & loss of function
- Elbows
- FFD common even early
- Radial head disease & synovitis common problem
- Can see Ulnar N entrapment
- Shoulders
- G-H & the A-C joints involved
- Rotator cuff disease common
- Hips
- Less common, later development
- May see Protrusio or AVN from steroids
- Knees
- One of most commonly affected
- Synovitis common
- FFD & valgus angular deformity common (although most are varus deformities)
- Bakers cyst common
- Feet & Ankles
- Subtalar joint more often affected than the ankle joint
- Subsequent planovalgus deformity seen
- Posterior tibial & peroneal tendonitis
- Can see plantar fasciitis or tendo achilles bursitis
- Mortons Neuroma seen
- Forefoot disease with
- Hallux valgus
- Lateral deviation of the lesser toes
- Clawing of toes
- MTPJ subluxation & distal progression of the fat pad
- Cervical Spine
- Intermittent neck stiffness & pain common
- Neurological symptoms rare
- Atlanto-axial instability & Basilar invagination of the odontoid can be seen
- Subaxial vertebrae may also demonstrate instability
Extra-Articular Involvement
- Nodules
- Occur in 25% of patients
- Pathognomonic
- Associated with IgM RF
- Most commonly occur on subcutaneous surface of forearms
- Also found in other areas of pressure
- Around knee
- Back of skull
- Bridge of nose with glasses
- Sacrum
- Flexor tendons with triggering
- Pleura & Lung
- Pericardium & Myocardium
- Larynx
- Sclera
- Differentiate from
- Gouty tophi
- BCC
- Xanthomata
- Sebaceous cyst
- Vasculitis
- Obliterative Endarteritis
- Digital vessels
- Nailfold lesions
- Cutaneous lesions of pulps
Raynaud's
- Inflammatory Vasculitis
- Polyneuritis
- Skin infarction & ulceration
- Neuropathy
- Spares the CNS but PNS often affected
- Mononeuritis Monoplex
- Related to vasculitis
- Symmetrical distal polyneuropathy
- NOT related to vasculitis
- Sensory Polyneuropathy
- OR
- Motor & Sensory Polyneuropathy
- More common in Seropositive men with chronic disease
- Entrapment Neuropathies
- CTS
- Ulnar Tunnel Syndrome
- Cubital Tunnel Syndrome
- Supinator Syndrome
- Tarsal Tunnel Syndrome
- Cervical Myelopathy
- Cord compression due to Atlantoaxial instability
- Myopathy
- Due to
- Myositis from vasculitis
- Steroids or Anti-malarial treatment
- Other manifestations
- Ocular
- All present with Red eye
- Include
- Episcleritis
- Keratoconjunctivitis Sicca/ Sjogren’s Syndrome
- Scleromalacia perfornans
- Gold & Chloroquinine treatment can cause ocular side effects
- Pulmonary
- Pleural effusions
- Intrapulmonary rheumatoid nodules
- Pneumoconiosis » Caplan’s Syndrome
- Pleurisy
- Diffuse Interstitial Fibrosis
- Pulmonary HT from vasculitis
- Cardiac
- Pericarditis
- Nodules causing
- Valvular insufficiency
- Conduction defects
- Lymphadenopathy
- Nodes draining affected joints
- Nodes at a distance
- Due to hyperactivity of RES
- Anaemia of Chronic Disease
- Normocytic normochromic
- Low Serum Iron
- Worst if iron loss due to NSAID
- Felty’s Syndrome
- Chronic RA & splenomegaly/ lymphadenopathy
- May also see skin pigmentation, leg ulcers, anaemia, thrombocytopaenia
- Gram positive infections common
