Rheumatoid Arthritis is a chronic inflammatory disease that affects mainly the joints, especially small joints – synovium, but can affect systemically. The disease is caused by an autoimmune response against an unknown self antigen(s).
- RA is more common in women
- Unknown etiology
- Chronic poly arthritis
- symmetric, erosive synovitis
- PIP
- MCP
- Wrists
- Knees
- Ankles
- MTP
- C Spine
Pathogenesis
Genetic predisposition along with environmental factors may trigger the development of rheumatoid arthritis (RA), with subsequent synovial T cell activation. CD4+ T cells become activated by antigenpresenting cells (APCs) through interactions between the T cell receptor and class II major histocompatibility complex (MHC)-peptide antigen. (see the diagram in Robins Pathology)
Clinical Presentation
- Morning stiffness – more than 1 hour – improves with activity, increases with rest
- Fatigue, depression, myalgia, weight loss (before the onset of arthritis)
- Ocular: episcleritis
- Lung: pleural effusions and nodules of parenchyma
- vasculitis
- Cervical vertebra: C1 – C2 subluxation
- Pericarditis
- Carpal tunnel syndrome
- Ruptured Baker cyst
Ligaments and tendons damage:
- Radial deviation of the wrist and ulnar deviation of the digits (MCP)
- Boutonniere deformity: ((PIP flexion with DIP hyperextension)
- PIP permanently bent toward the palm
- DIP bent back away
- Swan neck deformity: (DIP flexion with PIP hyperextension)
- Hammer toe, mallet toe, claw toe
Remember only DIP flexion in Swan Neck deformity
Rheumatoid Nodules:
- Tissue lump firm to touch
- Subcutaneous
- Usually found in olecranon, occiput, Achilles tendon
SYNDROMES IN RA
- Felty Syndrome = RA + Splenomegaly + Neutropenia
- Caplan Syndrome = RA + Pneumoconiosis
- Sicca Syndrome = dry eyes, mouth and other mucous membranes
Diagnostic Criteria (4)
- Morning stiffness “1 hour for 6 weeks
- Swelling of wrists, MCPs, PIPs for 6 weeks
- Swelling of 3 joints for 3 weeks
- RF positive or anti cyclic citrullinated peptide (anti CCP)
- ESR or CRP
Diagnosis

X-ray demonstrating progression of erosions on the proximal interphalangeal joint. (Courtesy of the American College of Rheumatology.)
based on criteria.
Diagnostic tests
- RF
- anti-CCP
- X-rays: erosion, osteopenia
- ESR or CRP elevated
- Anemia of chronic disease (decreased Hb)
Treatment
- NSAID
- STEROID
- DMARD
Disease Modifying Antirheumatic Drugs (DMARD)
- Methotrexate
- TNF inhibitors
- Adalimumab (Humira)
- Rituximab
- Etanercept
- Hydroxycholoroquine
- Alternate DMARDS: Sulfasalazine, Leflunomide
Surgical Therapy
Indication: structural joint damage. In early phases of the disease, an arthroscopic or open synovectomy may be performed. It consists of the removal of the inflamed synovia and prevents a quick destruction of the affected joints. Severely affected joints may require joint replacement surgery
MCQ POINTS
- Endotracheal intubation may be harmful in RA due to C1-C2 Spine involvement.