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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


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


    Extraarticular manifestations of rheumatoid arthritis. Copyright © 2012 The McGraw-Hill Companies.

  • 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


  1. Felty Syndrome = RA + Splenomegaly + Neutropenia
  2. Caplan Syndrome = RA + Pneumoconiosis
  3. 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


X-ray demonstrating progression of erosions on the proximal interphalangeal joint. (Courtesy of the American College of Rheumatology.)

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)



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

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  • Endotracheal intubation may be harmful in RA due to C1-C2 Spine involvement.
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