Rheumatoid Arthritis

dr Putra Hendra SpPD UNIBA

Rheumatoid Arthritis
Chronic, systemic inflammatory disease incidence 40-60 th Females 2-3X > Males Pathogenesis unknown

Endogenous factors MHC genes, genetik, hormon milieu)

Exogenous factors : rokok bacteria, viruses cross-reacting antigenes,

Synovial vasculitis

Adhesion molecule expression

cellular infiltration

Macrophages, T cells, B cells, granulocytes

Cytokines (TNF-a, IL-1, IL-6), RF, free-radicals, enzymes Synovial proliferation, angiogenesis, chondrocyte-, osteoclastactivation Pannus, cartilage destruction, bone resorption
Pathogenesis of RA

Cytokine Signaling Pathways Involved in Inflammatory Arthritis

Choy, E. H.S. et al. N Engl J Med 2001;344:907-916

Classification Criteria for RA

4 criteria present > 6 wks
1) Morning stiffness > 1

hour 2) Arthritis of 3 joints areas (PIP, MCP, wrist, elbow, knee, ankle, and MTP) 3) Arthritis of hand joints (wrist, MCP, PIP) 4) Symmetric arthritis

5) Rheumatoid nodules 6) RF+ 7) Radiographicchanges

Erosions Unequivocal periarticular osteopenia

Sites affected

RA: Joint distribution

Progression of RA..
Stage 1:
- no destructive changes. - Osteoporosis.

Stage 2:
- periarticular osteoporosis w/wo slight subchondral bone destruction. - joint mobility limit but no destruction. - adjacent muscle atrophy. - extra-articular soft tissue lesions.

Progression of RA..
Stage 3
- cartilage and bone destruction in addition to periarticular osteoporosis. - joint deformity w/wo fibrous or bony ankylosis. - extensive muscle atrophy. - extra-articular soft tissue lesions.

Stage 4
- criteria of stage 3. - fibrous or bony ankylosis.

RA
Early RA Intermediate RA Late RA

Courtesy of J. Cush, 2002.

RA Hand Deformity
Ulnar deviation at MCPs Radial deviation at wrists Swan-neck deformities Boutonniere deformities Tendon nodules Tendon rupture
3rd, 4th, and 5th extensor tendons

Carpal tunnel syndrome Ulnar neuropathy

Swan neck and Boutonniere

Ulnar Deviation

RA- extensor tendon rupture

Carpal Tunnel Syndrome

Deformities..

Rheumatoid nodules

RA - Knees
Symmetric lateral and medial joint space loss Effusions Synovial proliferation Bakers cyst
Posterior herniation of joint capsule May rupture
Hx and U/S can distinguish Crescent-sign on exam

Popliteal Cyst

Cock-up deformity

RA - Cervical Spine
Apophyseal joint destruction
C4-5 and C5-6 most common

Atlantoaxial Instability
C1-C2 Tenosynovitis of transverse ligament of C1 Erosion of odontoid process of C2
Cranial settling

Neck/Occiput pain, Paresthesias, Pathologic reflexes

RA: Other Features

RA - Vasculitis

RA - Vasculitis

Extraarticular RA -- Ocular
Sicca symptoms Episcleritis Scleritis

Scleromalacia perforans

RA: Pulmonary nodules

Laboratory ..
Hematologic parameters
Anaemia Thrombocytosis Serum iron & IBC Serum globuline ALP Acute phase reactant

Immunological parameters Synovial fluid analysis

Hematologic
Anemia of chronic disease
Low Fe, Low TIBC, Ferritin > 40 - 100

Feltys syndrome
Triad
RA Splenomegaly Neutropenia

Frequent infections/Leg ulcers

Iron deficiency anemia

(NSAIDs)

Lab Evidence of Inflammation

Synovial Fluid WBC > 2000/mm3 Serum Acute phase response
Acute phase proteins
CRP, ceruloplasmin, complement, serum amyloid A, fibrinogen, alpha-1-antitrypsin, haptoglobin, and ferritin Negative APPs = albumin, transferrin

Erythrocyte sedimentation rate

Laboratory RF
Rheumatoid Factor
Antibody against the Fc fragment of Ig Not sensitive
80% of RA patients

RF+ patients more likely to have

More severe disease Extraarticular manifestations

RF is not specific for RA.

Other autoimmune disease
Sjogrens syndrome , Systemic Lupus

Chronic infection
Hep B/C, SBE, Viral, Parasites, TB

Pulmonary inflammation
Sarcoid, IPF, Silicosis, Asbestosis

Malignancy Healthy 4% young; 5-25% > age 60

Anti-CCP
Anti-cyclic citrullinated peptide Specificity = 90% Sensitivity = 50-80%

Radiography
Periarticular osteopenia Symmetric joint space loss Marginal erosions Absence of productive changes Best films for diagnosis:
Bilateral Hand Arthritis Series Bilateral Foot Series

Larger joints may not show erosions early due to thicker cartilage.

RA - Erosions

RA - imaging

Differential Diagnosis
Viral polyarthritis Connective tissue disease Fibromyalgia Spondyloarthropathy Psoriatic arthritis Crystalline arthritis Septic arthritis Osteoarthritis Paraneoplastic disease Multicentric reticulohistiocytosis

RA -- Treatment
Aggressive treatment early! DMARDs = disease modifying antirheumatic drugs
Combinations

Biologics TNF-a inhibitors, IL-1 antagonists, Anti-CD20, CTLA4 Ig NSAIDs Steroids

Osteoporosis prophylaxis

Rheumatoid Arthritis prognosis

10% improve 60% intermittent, slowly worsening 20% severe joint erosion, multiple surgery 10% completely disabled