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Rheumatoid arthritis is a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints It has a prevalence of 1% and is more common in women than men (female:male ratio of 3:1) Rheumatoid arthritis can begin at any age, but the peak onset is in the fourth or fifth decade for women and the sixth to eighth decades for men The cause is not known Susceptibility to rheumatoid arthritis is genetically determined with multiple genes contributing Inheritance of class II HLA molecules with a distinctive five-amino-acid sequence known as the shared epitope is the best characterized genetic risk factor Untreated, rheumatoid arthritis causes joint destruction with consequent disability and shortens life expectancy Early, aggressive treatment is now the standard of care The pathologic findings in the joint include chronic synovitis with formation of a pannus, which erodes cartilage, bone, ligaments, and tendons In the acute phase, effusion and other manifestations of inflammation are common In the late stage, organization may result in fibrous ankylosis; true bony ankylosis is rare In both acute and chronic phases, inflammation of soft tissues around the joints may be prominent and is a significant factor in joint damage
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B Laboratory Findings
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Anti-CCP antibodies and rheumatoid factor, an IgM antibody directed against the Fc fragment of IgG, are present in 70 80% of patients with established rheumatoid arthritis but have sensitivities of only 50% in early disease AntiCCP antibodies are the most specific blood test for rheumatoid arthritis (specificity ~95%) Rheumatoid factor can occur in other autoimmune disease and in chronic infections, including hepatitis C, syphilis, subacute bacterial endocarditis, and tuberculosis The prevalence of rheumatoid factor positivity also rises with age in healthy individuals Approximately 20% of rheumatoid patients have antinuclear antibodies The ESR and levels of C-reactive protein are typically elevated in proportion to disease activity A moderate hypochromic normocytic anemia is common The white cell count is normal or slightly elevated, but leukopenia may occur, often in the presence of splenomegaly (eg, Felty s syndrome) The platelet count is often elevated, roughly in proportion to the severity of overall joint inflammation Initial joint fluid examination confirms the inflammatory nature of the arthritis (See Table 20 2) Arthrocentesis is needed to diagnose superimposed septic arthritis which is a common complication of rheumatoid arthritis and should be considered whenever a patient with rheumatoid arthritis has one joint inflamed out of proportion to the rest
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Clinical Findings
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A Symptoms and Signs
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1 Joint symptoms The clinical manifestations of rheumatoid disease are highly variable, but joint symptoms usually predominate Although acute presentations may occur, the onset of articular signs of inflammation is usually insidious, with prodromal symptoms of vague periarticular pain or stiffness Symmetric swelling of multiple joints with tenderness and pain is characteristic Monarticular disease is occasionally seen initially Stiffness persisting for more than 30 minutes (and usually many hours) is prominent in the morning; the duration of morning stiffness is a useful indicator of disease activity Stiffness may recur after daytime inactivity and be much more severe after strenuous activity Although any diarthrodial joint may be affected, PIP joints of the fingers, MCP joints, wrists, knees, ankles, and MTP joints are most often involved Synovial cysts and rupture of tendons may occur Entrapment syndromes are not unusual particularly of the median nerve at the carpal tunnel of the wrist Rheumatoid arthritis can affect the neck but spares the other components of the spine and does not involve the sacroiliac joints
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often produced by lung and gastrointestinal carcinomas, characterized by a rheumatoid-like arthritis associated with clubbing, periosteal new bone formation, and a negative rheumatoid factor Diffuse swelling of the hands with palmar fasciitis occurs in a variety of cancers, especially ovarian carcinoma
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Of all the laboratory tests, radiographic changes are the most specific for rheumatoid arthritis Radiographs obtained during the first 6 months of symptoms, however, are usually normal The earliest changes occur in the wrists or feet and consist of soft tissue swelling and juxta-articular demineralization Later, diagnostic changes of uniform joint space narrowing and erosions develop The erosions are often first evident at the ulnar styloid and at the juxtaarticular margin, where the bony surface is not protected by cartilage Diagnostic changes also occur in the cervical spine, with C1 2 subluxation, but these changes usually take many years to develop Although both MRI and ultrasonography are more sensitive than radiographs in detecting bony and soft tissue changes in rheumatoid arthritis, their value in early diagnosis relative to that of plain radiographs has not been established
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