1. RHEUMATOID ARTHRITIS (RA)
By:
DR.ABDALLAH FAHEL
1

2. RHEUMATOID ARTHRITIS (RA)
Gergely Péter dr
Definition: Chronic destructive of joint inflammation
with pain and swelling,mainly characterized by
inflammation of the lining( synovium) of the joints .In a
considerable proportion of patients, the arthritis is
progressive, resulting in joint destruction and
ultimately incapacitation and increased mortality.
Relatively common,
prevalence: 0.3-1.5 %
, the male:female ratio cca. 1:3.
Typical case: woman aged 30-40 years with polyarthritis
and early joint deformities.
2

3. History of Rheumatoid Arthritis
1858 – Dr Alfred Baring Garrod, named the condition Rheumatoid
Arthritis.
1895 – X-Ray was discovered.
1912 – Dr. Frank Billings introduced the concept of focal infection.
In the 1920’s, physicians suspected the cause of RA was bacterial
infection, they used gold and malaria drugs.
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4. RA in European Art
Dutch Priest 1631
4

5. Renoit in 1911
Wheelchair bound
w/ classic RA in his
hands
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6. Etiology :
1-gentic factor : may be involved because it is usually
associated with HLA-DR4
In white people and DR1 in indo-pak.
2-autoimmunity: RA is considered to be an
autoimmune disease for the following reasons:
*autoantibodies are present .
*immune comlex are common in synovial
Fluid.
There is defect in cell mediated immunity .
3-female gender: is a risk factor and this susceptibility
is increased post-partum and by breast feeding
4-cigarette smoking : is also a risk factor
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7. Pathogenesis :.
Is a disease of the synovium.
*inflammation :the synovium shows signs of chronic
inflammation .there swilling and congestion of synovial
membrane , and the underlying connective tissue which
becomes infilterated with lymphocyte,plasma cells and
macrophages .
*proliferation : the synovial membrane then proliferates and
grows out over the surface of the cartilage, which causes
erosion and destruction of the cartilage .
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8. Cytokine
Cytokinek
interactions
interakciói
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9. Rheumatoid Synovium
Normal Synovium
Rheumatoid Synovium
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10. 10

11. Symptoms of Rheumatoid Arthritis:
• Symptoms first begin in the small joints of the fingers, wrists and
feet, with warm, swollen
and tender joints that are painful and difficult to move.
• Joints of both sides of the body (symmetrical) are typically
affected.
• People with RA often experience fatigue, loss of appetite and
low-grade fever.
• There is often stiffness in the morning that lasts for several hours
or more.
• Nodules may form under the skin, often over the bony areas
exposed to pressure (such
as the elbows).
• Over time, damage to the cartilage and bone of the joints may
lead to joint deformities.
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12. Classification criteria of RA (ARA, 1987)
1. Morning stiffness – for at least 1 hr and present for at
least 6 weeks
2. Swelling of 3 or more joints for at least 6 weeks
3. Swelling of wrist, metacarpophalangeal (MCP) or
proximal interphalangeal (PIP) joints for at least 6
weeks
4. Symmetric joint swelling
5. Typical radiologic changes in hands (erosions or
unequivocal bony decalcification)
6. Rheumatoid nodules
7. Serum rheumatoid factor (RF) positivity
Diagnosis is made by the presence of 4 or more criteria
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13. Differential diagnosis of polyarthritis
RA should be differentiated from:
- Other autoimmune diseases (SLE, primary Sjögren’s syndrome,
MCTD, PM/DM, PSS, PAN, gian cell vasculitis, polymyalgia rheumatica,
adult onset Still’s disease)
- Viral diseases (parvovirus B19 infection, rubella, hepatitis B & C
infection)
- Bacterial infections (tbc, rheumatic fever, Jaccoud’s arthritis, septic
endocarditis, mycoplasma arthritis)
- Seronegative spondylarthritides (erosive psoriatic arthitis, reactive
arthritis, enteropathic arthritis)
- Paraneoplastic arthritis
- Other diseases (e.g. hyperthrophic osteoarthropathy, erythema
nodosum, agammaglobulinemia, acromegaly, diabetes mellitus)
- Other rheumatic diseases (chronic gout, inflamed erosive
osteoarthritis)
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14. Signs of early RA
(=undifferentiated arthritis)
In the early stage (within the first 3-6 months) (ARA)
classification criteria cannot be used.
The patient should be referred to a rheumatologist, if
•
•
•
the patient has 3 or more swollen joints
the metacarpophalangeal (MCP) and/or
metatarsophalangeal (MTP) joints are
involved; the squeeze test is positive
morning stiffness is 30 min or more.
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15. How to diagnose a case of
RA?
HISTORY:
Insidious onset
Slow development of sign & symptoms
Stiffness
Polyarticular
Most common: PIP & MCP of hands
Morning stiffness > 1hr
Fatigue, malaise, depression
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16. Squeeze test
16

17. Joint involvement in RA
The most specific sign of RA is arthritis.
It is progressive and deforming in the
majority (2/3) of cases (= erosive
polyarthritis)
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18. RA early stage
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19. Early assymmetric RA
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20. PIP joint involvement in RA
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21. RA: swan neck deformity
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22. RA: ulnar deviation
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23. Ulnar deviation in RA with severe atrophy of interosseal
muscles
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24. RA: Boutonnière deformity
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25. RA: arthritis mutilans
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26. Involvement of joints of feet in RA
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27. Severe destruction of ankles in RA
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28. Baker’s cyst
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29. Bursitis in the shoulder
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30. Bursitis and rheumatoid nodule
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31. Rheumatoid nodules
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32. RA – end stage
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33. Laboratory Tests
Initial work-up
CBC, Metabolic panel, Urinalysis,
Rheumatoid factor, Anti-nuclear antibody.
Chem: nl, slight decr albumin, incr total
protein.
Hema:hemocrit- ACD, wbc- mildly up,
platelet- rare thrombocytosis
ESR: elevated
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34. Radiology:
X-Ray
MRI
Bone Scan
Symmetrical
1-Early: no sig changes
2-Late:
-Juxta-articular osteoporosis w/ decr bone density
*Uniform jt narrowing.
*Marginal erosions.
*Marginal cortical erosions
*Juxtaarticular osteoporosis of lesser mets
Ill-defined ersosion of posteroanterior aspect of calcaneus
Resiters, PA, AS, hyperparathyroidism
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35. Periarticular osteoporosis (decalcification)
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36. Erosions and sclerosis (in late stage)
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37. Erosion in RA
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38. Early erosions (MRI)
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39. Scintigraphy of
the hands
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40. Atlantoaxial
subluxation
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41. Extraarticular manifestations of RA
• rheumatoid nodules
•
•
•
•
•
– subcutaneous
- in internal organs (lung,
aortic valve)
pleuritis/pericarditis
fibrotizing alveolitis
Felty’s syndrome
vasculitis
amyloidosis
41

42. Systemic
manifestations of
RA:
pulmonary fibrosis
42

43. Interstitial pneumonitis in RA
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44. Systemic
manifestations of
RA:
Caplan’s syndrome
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45. Rheumatoid nodules in the lungs
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46. Episcleritis in RA
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47. Scleritis in RA
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48. Scleromalacia perforans
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49. Vasculitis in RA
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50. Vasculitis in RA
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51. Leg ulcers in Felty’s
syndrome
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52. Large granular lymphocytes in Felty’s syndrome
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53. What is “Quality of Life”?
• Ability to
– Work
– Be a parent
– Socialize with others
– Exercise and be mobile
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54. Management of Rheumatoid Arthritis:
• The goals of treatment of RA are to reduce joint pain and
swelling, relieve stiffness and
prevent joint damage.
• Evaluation by a rheumatologist for the development and
monitoring of a treatment plan is
required in most people with RA.
• Treatment plans often include a combination of rest, physical
activity, joint protection, use
of heat or cold to reduce pain, and physical or occupational
therapy.
• Maintain a healthy body weight and maintain a physical activity
plan (i.e. Arthritis
.
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55. • Drugs play a very important role in the treatment of RA.
• Many people with RA take nonsteroidal anti-inflammatory drugs
(NSAIDs) to help reduce
joint pain, stiffness and swelling.
• Low doses of corticosteroids such as prednisone may also be
used to relieve joint pain,
stiffness and swelling and to reduce the risk of joint swelling.
• People with RA are often treated with disease-modifying antirheumatic drugs
(DMARDs), such as methotrexate or leflunomide
55

56. Disease modifying antirheumatic drugs (DMARD):
Drug
gold (i.m.)
Adverse effects
Dose
dermatitis, stomatitis,
25-50 mg /2-4
proteinuria, enterocolitis,
weeks
thrombocytopenia
gold (p.o.)
less frequently used, brecause of lower
tolerability
chloroquine (hydroxy- retinopathia, pigment250 mg/day
chloroquine)
anomalies
Regular ophthalmology check is required
d-penicillamine
proteinuria, myasthenia,
125-750 mg/day
stomatitis
Owing to low tolerability it is not used any more
azathioprine
hepatitis, bone marrow depression 50-150
mg/day
Scarcely given in RA
methotrexate
hepatotoxicity, pulmonary fibrosis, 7,5-25
(MTX)
bone marrow depression
mg/week
most frequently used therapy
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57. sulfasalazine
cyclosporine A
leflunomide
TNF- blockers:
(etanercept,
infliximab, and
abatacept)
nausea, vomiting
1,5-2 g/day
diarrhea, bone marrow depression
nephrotoxicity, tremor
1,5-4 mg/kg/day
creatinine and blood pressure should be
checked regularly
hepatotoxicity, GI
10-20 mg/day
complaints
local reaction, autoimmune disease (SLE, SM)
infection (tbc)
etanercept: 25 mg 2x weekly s.c.
infliximab: 3 mg/kg every 8 week i.v.
Other:
anakinra (IL-1 blocker)
rituximab (anti-CD20 antibody)
abatacept (T cell activation blocker antibody)
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58. THANK YOU
DR.ABDALLAH FAHEL
58