A chronic multisystem disease of unknown

etiology characterized by persistent

inflammatory synovitis involving peripheral
joints in a symmetric fashion
Hallmarks :
Cartilaginous destruction, bony erosions,
and joint deformity
The course is variable



An immunologically mediated event in
which joint injury occurs from synovial
hyperplasia; lymphocytes infiltration of
synovium; and local production of
cytokines and chemokines by activated
lymphocytes, macrophages, and
fibroblasts
RA occurs in 0.8 % of the population
Women affected 3 times more often
than men
Prevalence increases with age
Onset most frequent in fourth and fifth
decades
Articular Manifestations
A symmetric polyarthritis of peripheral
joints with pain, tenderness and swelling
of affected joints
Morning stiffness
PIP and MCP joints involved
Joints deformities may develop after
persistent inflammation
Extraarticular Manifestations
Cutaneous rheumatoid nodules,
vasculitis
Pulmonary nodules, interstitial disease
Ocular episcleritis, scleritis
Hematologic anemia , feltys syndrome
Cardiac pericarditis, myocarditis
Neurologic myelopathies secondary to
cervical spine disease
Hx and physical exam
Rheumatoid factor is present in 85 % of pts;
its presence correlates with severe disease,
nodules, extraarticular features
Other laboratories : CBC, ESR
Synovial fluids analysis
Radiograph juxtaarticular osteopenia, joint
space narrowing, marginal erosions. CXR should
be obtained
Not difficult in pts with typical
established disease
May be confusing early
Classification criteria were developed
for investigational purposes
Differential diagnosis :
Gout, SLE, psoriatic arthritis, infectious
arthritis, osteoarthritis, sarcoid
CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS
[*]

1. Morning stiffness (1 hr)
2. Swelling (soft tissue) of three or more joints
3. Swelling (soft tissue) of hand joints (PIP, MCP, or wrist)
4. Symmetrical swelling (soft tissue)
5. Subcutaneous nodules
6. Serum rheumatoid factor
7. Erosions and/or periarticular osteopenia in hand or wrist joints seen
on radiograph
*
Criteria 1 through 4 must have been continuously present for 6 wk or
longer, and criteria 2 through 5 must be observed by a physician
. A classification as rheumatoid arthritis requires that four of the seven
criteria be fulfilled. MCP = metacarpophalangeal; PIP = proximal
interphalangeal

TABLE 285-3 -- DIFFERENTIAL DIAGNOSIS OF
RHEUMATOID ARTHRITIS
Disorder Subcutaneous Nodules Rheumatoid Factor
-Viral arthritis (hepatitis B and C, parvovirus,
rubella, others)
- Bacterial endocarditis
+ Rheumatic fever +
- Sarcoidosis + + Reactive arthritis - - Psoriatic
arthritis - - Systemic lupus erythematosus
+ Primary Sjgren's syndrome
+ Chronic tophus gout + - Calcium pyrophosphate
disease - -
Polymyalgia rheumatica - - Osteoarthritis (erosive) -
- - = not present; + = frequently present; =
occasionally present

Pt education on disease, joint protection
Physical and occupational therapy
Aspirin or NSAIDs
Intra articular glucocorticoids
Systemic glucocorticoids
DMARDs (Disease Moving Anti Rheumatic
Drugs)
Anti-cytokine therapy
Immunosuppressive therapy
Surgery may be considered