Rheumatoid arthritis

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Rheumatoid Arthritis of Hip
Rheumatoid Factor
Rheumatoid Nodules

Rheumatoid arthritis

Presentation

• bilateral, symmetrical

• Joint Pain

• Swelling

• Stiffness

• Fatigue

• Malaise

Differential Diagnosis

• post-viral arthritis

• seronegative arthritis

• polymyalgia rheumatica

• acute nodal osteoarthritis

History

• Which Joints

  • often affects small joints of hands and feet

  • Hip

• Stiffness

  • Duration of 'early morning stiffness' typically 30mins - 1 hour

  • may get after staying in one position

• Acute joint swellings

• Disability

  • buttons

  • hair

  • climbing stairs

  • walking

• Chest pain

  • pericarditis

• Short of Breath

  • Pleural Effusion

  • Fibrosing Alveolitis

  • Anaemia

• Dry Eyes

Examination

• General

  • wasting

  • Cushing's Syndrome

• Hands

  • Ask if painful

  • Nails

    • nail bed infarcts

  • Skin

    • steroidal

      • atrophic 

      • purpura

    • Raynaud's Syndrome

    • ulcers over nodules

  • Joints

    • symmetrical esp. metacarpo-phalangeal,

    • soft tissue swellings

    • spindling of fingers

    • swelling

    • redness

    • synovitis

    • ulnar deviation of fingers

    • swan neck deformity

    • Boutonnière deformity

    • Z deformity of thumb

    • subluxation of proximal phalanx

  • Nerves

    • wasting small muscle of hand

    • generalised weakness

    • grip strength decreased with severity

    • change if co-existing 

      • carpal tunnel syndrome

      • polyneuropathy

      • ulnar entrapment at elbow

• Knees

  • Genu valgum

  • effusion

  • limitation of movement

  • crepitus

  • joint instability

• Extras

  • rheumatoid nodules over tendons 

    • especially elbow

Criteria for Diagnosis

(American College of Rheumatology)

Need four or more

• for 6 weeks or more

  • morning stiffness >1 hour

  • arthritis of three or more joints

  • arthritis of hand joints and wrists

  • symmetrical arthritis

• subcutaneous nodules

• positive serum rheumatoid factor

• typical radiological changes

Pathology

• Synovium main tissue affected

• mononuclear cell / lympohcyte infiltrate

  • hypertrophy of synovium

  • pain

  • inflammation

• Vessels surrounded by activated antigen presenting cells (MHC-II positive) and activated T-cells (mainly memory CD4+)

• Some B / plasma cells

• PMN common in synovial fluid, rare in membrane

• New vessels formation and endothelial proliferation

• Pannus formation

  • forms at margin of synovium and hyaline cartilage

  • erodes cartilage

    • causes pain

    • destroys joint

Immune Complexes

• activate complement and stimulate inflammation

Extra-articular Manifestations

• rheumatoid nodules

• vasculitis

• lymphadenopathy

• pulmonary changes

  • fibrosis

  • nodules

  • pleurisy

  • pleural effusion

  • Chronic Obstructive Airways Disease

  • bronchiolitis obliterans

• eyes

  • episcleritis

  • scleritis

  • scleromalacia

  • scleromalacia perforans

• cardiac

  • pericarditis

  • myocarditis

• neurological

  • cervical cord compression

  • entrapment neuropathies

    • Carpal Tunnel Syndrome

  • peripheral neuropathy

• renal

  • amyloid

Complications

• risk factor for placental abruption

• Anaemia of Chronic Disease

• Aortic Regurgitation

• Bronchiectasis

Investigations

• ESR
• Shirmer's test
  • for dry eyes

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