Rheumatoid Arthritis Clinical Features - Rheumatic Disorders & Tendinitis

Clinical Features

Typically insidious 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 perforans
  - Gold & Chloroquine 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