RA: Clinical Aspects



- See: Stages of Rheumatoid Arthritis

- Discussion:
    - affects 1-3% of adult population;
    - female predominance of about 3 to 1;
    - peak age of onset 35 and 45 years;
    - most often presents with involvement in the feet and hands (intial involvement occurs in 15% and 14%, respectively);
    - poor prognostic factors:
          - high latex fixation titer;
          - rheumatoid nodules;
          - rapid rate of radiographic joint destruction;
          - poor response to medications;
    - diff dx:
          - systemic lupus erythematosus;
          - scleroderma;
          - dermatomyositis;
          - seronegative arthritis;
                 - psoriatic arthritis;
                 - Reiter's syndrome;
                 - AS;
                 - arthritis of chronic inflammatory bowel disease;
         - rarely, polyarticular crystal deposition disease, polyarticular septic arthritis, & host of very unusual entities may be confused w/ RA;


- Clinical Manifestations:
    - symmetrical polyarthralgias, morning stiffness, and fatigue are common;
    - general fatigue and malaise may be present before joint symptoms;
    - morning stiffness results from increases in extracellular fluid in & around joint;
    - later on, there may be limitation of motion due to pain or joint destruction;
    - although RA may involve any synovial joint, there is predilection for wrists and hands;
          - MP joints, PIP joints, and wrists are first to become symptomatic;
          - ulnar deviation, and swan-neck or boutonniere deformities are common;


- Extra Articular Manifestations:
    - patients with extraarticular manifestations have increased mortality rate as well as more severe disability;
    - extra-articular manifestations are more common w/ high-titer RF;
    - heart (pericarditis, cardiomyopathy, and valvular incompetence caused by nodules, and interstitial fibrosis);
    - eyes (scleritis, and occasionally scleromalacia perforans);
           - rheumatoid scleritis is the most common ocular complication of RA, and generally indicates a poor prognosis;
           - it is often associated w/ skin nodules, and a high titre of RF;
           - incidence of iritis in RA is no greater than that found in general population;
           - nodular scleritis is a more advanced stage of the previous case;
    - nervous system (mononeuritis multiplex, and peripheral compression syndromes such as median neuropathy);
           - vasculitic neuropathy occurs in 10% of these patients and in half of these patients (5%), neuropathies are predominantly sensory, whereas others (5%) present with a slowly progressive, distal symmetrical sensory or sensory-motor polyneuropathy;
           - these neuropathies appear in severe and long-standing rheumatoid arthritis;
    - kidneys (amyloid deposition);
    - hematopoietic system (Felty's syndrome):
           - anemia, splenomegaly, and leukopenia;
    - vasculitis:
           - usually is a non necrotising arteritis of the small terminal arterials, but occassionally taking the form of a fulminating arteritis;
           - skin lesions, leg ulcers, necrotizing arteritis of the viscera, digital infarctions, and fever;
    - Sjogren's syndrome:
           - occurs in about 15% of RA pts;
           - due to infiltration of exocrine glands w/ lymphocytes;
           - keratoconjunctivitis, xerostomia, & lymphoid infiltration of parenchymal organs may occur;
           - patients are at increased risk for developing lymphoid malignancies;


- Pathologic Changes in Specific Joints:
    - cervical spine
    - hand
            - boutonniere
            - extensor tendon rupture 
            - flexor tendon rupture 
            - MP joint 
            - thumb
            - swan neck deformity
            - PIP joint
    - wrist
            - radioulnar / radiocarpal joints
            - caput ulna syndrome
    - elbow
    - hip
    - foot



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 21, 2012 2:37 pm