Rheumatoid Arthritis

Question 1

Define:

Answer 1

• Chronic inflammatory systemic disease characterised by symmetrical deforming peripheral polyarthritis and extra-articular manifestations

Question 2

Aetiology/risk factors:

Answer 2

• AUTOIMMUNE disease
• UNKNOWN cause
• Associated with other autoimmune diseases (e.g. Sjogren’s syndrome)
• HLA associations:
o HLA-DR1
o HLA-DR4
• Rheumatoid factor is an IgM antibody which recognise the Fc portion of IgG as their target antigen (IgM anti-IgG antibody) – has M in its name

Question 3

Epidemiology:

Answer 3

• COMMON
• 1% of general population
• 3 x more common in FEMALES
• Peak incidence: 30-50 yrs

Question 4

Symptoms:

Answer 4

• Typical picture: symmetrical, swollen, painful and stiff small joints of hands and feet, worse in the morning
• GRADUAL onset
• Joint pain – polyarthric involvement including large and small joints
• Swelling
• Morning stiffness lasting >1 hour – improves with motility
• Impaired function
• Usually affects peripheral joints symmetrically

Question 5

What are systemic symptoms:

Answer 5

•	Systemic Symptoms: FFWPP
o	Fever 
o	Fatigue 
o	Weight loss 
o	Pericarditis
o	Pleurisy

Question 6

Early signs:

Answer 6

o Spindling of fingers
o Swelling of MCP and PIP or MTP joints – usually symmetrical (DIP is spared)
o Warm, tender joints
o Reduction in range of movement

Question 7

Late signs:

Answer 7

o	Symmetrical deforming arthropathy
o	Ulnar deviation of fingers as a result of subluxation (partial dislocation) of the MCP joints 
o	Radial deviation of the wrist 
o	Swan neck deformity (image 1)
o	Boutonniere deformity (image 2)
o	Z deformity of the thumb 
o	Trigger finger (inability to straighten the finger, tendon nodule palpable) 
o	Tendon rupture 
o	Wasting of small muscles of the hand 
o	Palmar erythema

Question 8

Extra articular signs:

Answer 8

Rheumatoid Nodules - firm subcutaneous nodules (usually found on the elbows, ulnar margin, palms and over extensor tendons)
lymphadenopathy,
vasculitis
fibrosing alveolitis
obliterative bronchiolitis
pleural and pericardial effusion
Raynaud’s
carpal tunnel syndrome
peripheral neuropathy
splenomegaly

Question 9

Investigations:

Answer 9

o FBC - low Hb (ACD), high platelets (inflammation)
o High ESR and CRP
o Rheumatoid factor (found in 70% of RhA patients)

o Antinuclear antibodies (30%) – anti-cyclic citrullinated peptide antibodies are highly specific for RA
• Joint Aspiration
o May be performed in the acute setting to rule out septic arthritis

Joint X-Ray - BONDS
o	Deformity
o	Osteopaenia – low bone density
o	Narrowing of joint space 
o	Bone erosions
o	Soft tissue swelling 

Ultrasound and MRI