Rheumatoid Arthritis
Dr. C. C. Visser
MBChB MMed (Med Phys) Diploma in Orthopaedic Medicine Member of the Society of Orthopaedic Medicine, UK
Arthritis
OA
Primary: DIP PIP,hip,knee spine, 1 MTP Secondary:
Crystal
Gout Pseudogout
RA
SpA
AS Psoriatic Enteropathic Reactive
CTD
SLE PSS PM/DM MCTD
Vasculitis
PAN, Wegeners Takayasu, GCA etc
Cartilage
Cartilage Synovium Soft tissue Bone Synovial fluid XR Urate level
Synovium
Joints + C-spine >> Systemic
Synovium Entheses
Axial + peripheral joints>> systemic
Synovium
Systemic >> Synovium
Synovium
Systemic >> Synovium
XR
RF XR
XR HLA B27
ANF ENA Organ Fx tests
ANCA Histology Imaging
Rheumatoid arthritis
• Most common form of inflammatory arthritis • Affects 1 % of all populations
• Females > males 3:1
Rheumatoid Arthritis
• Wide variation in
– age at onset – degree of joint involvement – severity of disease
• Difficult to predict early on who will develop more severe disease
Effects of RA
• Systemic disease but joint involvement dominates
• RA affects morbidity and mortality • RA reduces life expectancy
– males by 7 year – females by 3 years
Etiology
• Immune mediated chronic inflammation • Trigger: Environmental Genetic (30%)
Antigen Self Antigen
T cell activation
Chronic Inflammation Lymphoid cells infiltrate synovium New blood vessels form in synovium Synovial proliferation Joint destruction
Mechanisms of joint damage
• Synovial mass stretches joint capsule and ligaments: joint swelling, instability & deformity • Cytokine and proteolytic enzyme rich synovial fluid destroys cartilage joint space narrowing on X-rays • Infiltration of cartilage and later bone by invading synovium (pannus) marginal erosions
Onset
• 60% insidious onset of pain, stiffness, symmetrical swelling of joints especially small joints • 20% acute or subacute • 10% vague aches and pains • 5% systemic symptoms: fatigue, malaise, weight loss, low fever, myalgia, morning stiffness, depression
ACR Classification Criteria (4/7)
• • • • • • • EMS > 1 hour > 3 joint arthritis Symmetrical arthritis Wrist, MCP, PIP arthritis Rheumatoid nodules Rheumatoid factor X-ray changes: periarticular osteopaenia/marginal erosions
Articular involvement
Articular involvement
Any synovial joint can be involved
Also inflammation of synovium in bursae and tendon sheaths Can start asymmetrically with only few joints affected
Articular involvement
• Spreads within months to years to other joints in symmetrical distribution
• Joint involvement reaches a plateau after first few years • Number of joints affected in early disease related to severity of disease
Hand
• MCP joints
– Synovitis – Ulnar deviation
• PIP joints
– Synovitis – Swan neck deformity – Boutonniere deformity
• Z-deformity of thumb • Tendons
– Flexor tenosynovitis – Extensor tenosynovitis
• Poor grip: power and pinch
Wrist
• • • • • • Synovitis Piano key sign (distal radio-ulnar joint) Subluxation Radial deviation Ankylosis Carpal tunnel syndrome
Elbow
• Synovitis • Flexion contracture • Decreased, painful pronation and supination • Olecranon bursitis • RA nodules
Shoulder
• • • • Subacromial bursitis Rotator cuff tendinitis Glenohumeral joint arthritis Acromio-clavicular arthritis
Foot
• MTP
– Synovitis – Subluxation with hammer/claw toe and metatarsalgia – Bunions – Bunionettes – Toe deviation/overriding
• Collapse of medial arch of foot
Ankle/Hindfoot
• Ankle
– Synovitis – Retrocalcaneal bursitis
• Tenosynovitis/rupture
– Peroneal tendons – Tibialis posterior
• Subtalar arthritis
– Reduced and painful movement – Hindfoot valgus
Knee
• • • • • Synovitis Effusions Baker’s cyst +/- rupture Instability/ deformity eg valgus deformity Flexion contracture
Hip
• Arthritis (usually late)
– Pain especially on weight bearing – Reduced movement
• Trochanteric bursitis
Cervical spine
• Involved in 70% patients with longstanding RA • Occipital pain made worse by movement • Subluxation of C1-2 with compression of spinal cord during neck flexion
– Significant if >10 mm instability on flexion – Usually slowly developing myelopathy
• Subaxial subluxation
Serial cervical X-rays in a RA patient
Other joints
• TMJ: reduced mouth opening
• Sternoclavicular • Crico-arytenoid • Ossicles of ears
Non-articular manifestations
Non-articular manifestations
• Generalized lymphadenopathy
• Nodules
– 30% patients – external over areas of pressure – internally eg lung, heart, gallbladder – central necrosis with pallisade of fibroblasts
Non-articular manifestations
• Lungs
– Pleurisy – Pleural effusions (NB exudate!) – RA nodules single/multiple (Caplan syndrome if huge nodules in coal miners) – Lung fibrosis
Non-articular manifestations
• Heart
– pericarditis, usually asymptomatic, but can lead to friction rubs / effusions / tamponade – RA nodules: conduction defects
Non-articular manifestations
• Bone
– Generalized osteoporosis
• Muscle
– Muscle atrophy – Rarely myositis
Non-articular manifestations
• Skin
– Palmar erythaema – Digital gangrene (small arteries) – Nail fold infarcts (small arteries) – Skin ulcers (medium arteries) – Purpuric papules (venules) – Palpable purpura (leukocytoclastic vasculitis)
Non-articular manifestations
• Eyes
– Secondary Sjögren syndrome – Episcleritis – Scleritis – Scleromalacia perforans
Complications
Complications
• Infections
– More susceptible to any infection (RA, steroids, MTX) – ESPECIALLY susceptible to joint infections – Always suspect septic arthritis if sudden increase in symptoms in one joint
Complications
• Felty syndrome
– Splenomegaly and low WBC in RA
• Neurological
– Entrapment neuropathy: CTS, ulnar nerve, tarsal tunnel syndrome – Mononeuritis multiplex (RA vasculitis) – Atlanto-axial subluxation with cord compression
Complications
• Osteoporosis and fractures
– RA – Immobility – Steroids
• Amyloidosis
– Rare – Longstanding disease – Proteinuria/decreased renal function
Special investigations
Laboratory diagnosis
• Rheumatoid factor
• Raised markers of inflammation (ESR/ CRP)
• LFT abnormalities
– Raised ALP – Raised proteins (polyclonal rise in globulins, often also low albumin)
• FBC abnormalities:
– Anaemia of chronic disease – Reactive thrombocytosis
Rheumatoid factor
• Antibodies against human IgG Fc • 1-5% of normal people
• Also in chronic infections and inflammation eg TB, endocarditis and liver cirrhosis
Radiological diagnosis
• • • • Periarticular soft tissue swelling Periarticular osteopaenia Joint space narrowing Marginal joint erosions leading eventually to complete joint destruction • Subchondral cysts • Compressive changes due to collapse of osteoporotic subchondral bone eg protrusio acetabuli at hip
Serial X-rays of a knee in RA
Treatment
Multidisciplinary Care
• • • • • • • Rheumatologist Orthopaedic Surgeon Physiotherapist Occupational therapist Orthotist Psychologist Community based support systems
– Arthritis Foundation – Patient Partners – Support Groups
Medical Treatment
• Greatest and irreversible joint damage occur early in disease • Thus: Treat early and aggressively • No single treatment regimen consistently halts disease progression
Medical Treatment
Symptomatic:
NSAID’s, paracetamol, opioids, low dose steroids, atypical analgesics
Intra-articular steroids Disease modifiers: Slow acting and side effects!
Methotrexate, Chloroquine, Sulphasalazine, Dpenicillamine, gold salts, leflunomide, high doses steroids, immunosuppressants, biologicals (anti TNF alpha and IL-1 agents)
Surgical Treatment
• Soft tissue:
– Carpal tunnel release – Synovectomy – Tendon transfers
• Joint replacement • Arthodesis • Excision arthroplasty eg radial head
Treatment
• Rest vs exercise
• Diet
– Avoid obesity – “Anti-inflammatory diet”: vegetarian with omega 3 fatty acids (fatty fish/fish oils) – Essential fatty acids (evening primrose oil) – Anti-oxidants?