rheumatoid arthritis(ra)
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Rheumatoid Arthritis(RA). Dr. Gehan Mohamed. Learning objectives:. At the end of this lecture the student should be able to : understand definition,genetic predisposition of RA. Discuss pathophysiology, clinical features of RA. - PowerPoint PPT PresentationTRANSCRIPT
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Rheumatoid Arthritis(RA)
Dr. Gehan Mohamed
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Learning objectives: At the end of this lecture the student should be able
to : understand definition,genetic predisposition of RA. Discuss pathophysiology, clinical features of RA. Identify Diagnostic Criteria ,Laboratory Features and
bad prognostic Features of Rheumatoid Arthritis.
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RA Systemic inflammatory autoimmune
disorder Age incidence : 40-70 years of age
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Genetics
Patients which have HLA-DRB have Increased risk for : RA development. Increased joint damage Increased joint need for surgery
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Pathophysiology
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Role of Immunolog in RA Macrophages:
Produce cytokines Cytokines (TNF-α) cause
systemic features Release chemokines recruit
PMNs into synovial fluid/membrane
TNF-α & IL-1: Proliferation of T cells Activation of B cells Initiates proinflammatory/joint-
damaging processes
TH-1 cells: Mediate disease processes Activate B cells
B cells: Release cytokines Plasma cells that produce
Ab
Osteoclasts induce: Bone erosion Juxta-articular & Systemic
osteoporosis
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Pathophysiology Swelling of Synovial lining
Angiogenesis
Pannus formation in form of : Synovial thickening/hyperplasia Inflammatory vascularized tissue Generation of Metalloproteinases
Cytokine release Infiltration of leukocytes Change in cell-surface adhesion molecules & cytokines Destruction of bone & cartilage
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Sequence of events : Proliferation of synovial membrane
cells with inflammatory cell infiltrate Destruction of joints Disability
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Diagnosis:1- clinical criteria2- investigations
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1- Diagnostic Criteria Symmetric peripheral polyarthritis Morning Stiffness >1 hour Extraarticular manifestations Rheumatoid nodules
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Symmetric Peripheral Polyarthritis 3 or more Joints for >6 weeks Intermittent or Migratory involvement
Small Joints Hands & Feet Peripheral to Proximal
Leads to Deformity & Destruction of Joints Erosion of cartilage and bone
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Stiffness Morning or after Prolonged Inactivity Bilateral > 1 hours
Reflects severe joint inflammation Better with movement Pain with pressure to joint Pain with movement of joint Swelling due to hypertrophy of synovium Effusion Hottness Redness
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Physical Exam Decreased grip strength Carpal tunnel syndrome(condition
characterized by pain and numbing or tingling sensations in the hand and caused by compression of a nerve in the carpal tunnel at the wrist.
Ulnar deviation Boutonniere/Swan neck deformities Extensor tendon rupture
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Extraarticular Involvement Myalgia, fatigue,
low-grade fever, weight loss, depression.
Anemia Rheumatoid nodules Pleuropericarditis Neuropathy
Scleritis Splenomegaly Vasculitis
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Rheumatoid Nodules Extensor surfaces
elbows Very Specific Only occur in ~30% Late in Disease
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Investigations
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Arthrocentesis Confirm diagnoses Differentiate between inflammatory & noninflammatory Labs:
White blood cell count if WBC >2000/µL indicates inflammatory arthritis
Gram stain & Culture
Arthroscopy Evaluate ligamentous & cartilaginous integrity Biopsy Infection: aspirate thick
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Rheumatoid arthritis : showing inflammatory cell infiltrate in the synovium
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Laboratory Features Rhumatoid Factor
70-80% of pts. - Lab manifestations up to 10 years before clinical - IgM or IgG - If IgM+ve : more severe disease & poorer
outcome. Overlap with Hepatitis C Virus.
Acute Phase reactants ESR, CRP monitoring disease activity
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Radiology Evaluate disease activity & joint
damage Bony decalcification
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Radiological Studies Plain Films
Bilateral hands & feet
Color Doppler U/S & MRI Early signs of damage i.e. Erosions Bone Edema - even with normal findings on
radiography
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DiseaseSeverity
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Arthralgias >3 inflamed joints Mild functional limitation Minimally elevated ESR & CRP No erosions/cartilage loss No extraarticular disease
Mild Disease
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Moderate Disease 6-20 Inflamed joints Moderate functional limitation Elevated ESR/CRP Radiographic evidence of
inflammation No extraarticular disease
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Severe Disease >20 persistently inflamed joints Rapid decline in functional capacity Radiographic evidence of rapid
progession of bony erosions & loss of cartilage
Extraarticular disease
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bad prognostic Features RF +ve Early development of multiple inflamed joints
and joint erosions Severe functional limitation Female HLA epitope presence Lower socioeconomic status & Less education Persistent joint inflammation for >12 weeks
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Differential diagnosis of arthritis
Seronegative polyarthritis Psoriatic arthritis Osteoarthritis SLE Paraneoplastic syndrome Crystal-induced arthritis
Tophaceous gout Pseudogout