Rheumatoid Arthritis
         (RA)
• A chronic, systemic disease
  characterized by inflammation of
  connective tissue in...
Rheumatoid Arthritis
           (RA)
• Affects all ethnic groups
• Can occur at any time of life
• Incidence ↑ with age
• ...
Etiology and
      Pathophysiology
• Cause of RA is unknown
• No infectious agent has been
  cultured from blood and synov...
Etiology and
      Pathophysiology
• Autoimmunity
  – Changes begin when a susceptible host
    experiences an initial imm...
Etiology and
       Pathophysiology
• Autoimmunity
  – RA is characterized by the presence of
    autoantibodies (rheumato...
Etiology and
    Pathophysiology
• Autoimmunity
  – Joint changes from chronic inflammation
    begin when the hypertrophi...
Etiology and
        Pathophysiology
• Autoimmunity
  – Pannus (a proliferation of synovial tissue)
    forms within the j...
A. Synovial swelling & fluid accululation
B. Pannus, eroded articular cartilage &
        joint space narrowing
Joint space narrowing and
       osteophytes
Etiology and
       Pathophysiology
• Genetic factors
  – Genetic predisposition appears to be
    important in the develo...
Clinical Manifestations
                 Joints
• Onset of RA is typically insidious
• Nonspecific manifestations may
  pr...
Clinical Manifestations
               Joints
• Stiffness becomes more localized in
  the following weeks to months
• Some...
Clinical Manifestations
                 Joints
• Specific joint involvement
  –   Pain
  –   Stiffness
  –   Limitation o...
Clinical Manifestations
                Joints
• Joint symptoms occur symmetrically
  and frequently
  – Small joints of t...
Clinical Manifestations
             Joints
• Often experience joint stiffness
  after periods of inactivity
• Morning sti...
Clinical Manifestations
                Joints
• Joint pain
  – ↑ with motion
  – Varies in intensity
  – May not be propo...
Clinical Manifestations
               Joints
• Inflammation and fibrosis of the
  joint capsule and supporting
  structur...
Early Rheumatoid
     Athritis
Advanced Rheumatoid
      Athritis
Deformities of RA




                    Fig. 63-4
Clinical Manifestations
Extraarticular Manifestations
• RA can affect nearly every system of
  the body
• Three most commo...
Extraarticular Manifestations of RA




                                 Fig. 63-5
Rheumatoid Nodules
• Develop in 25% of all patients with
  RA
• Usually have high titers of RF
• Appear as firm, nontender...
Rheumatoid Nodules
• Nodules at the base of the spine and
  back of the head are common in older
  adults
• Develop insidi...
Rheumatoid Nodules
Rheumatoid Nodules -
      elbow
Rheumatoid Nodules
Complications
• Flexion contractures and hand
  deformities
  – Cause diminished grasp strength
  – Affect the patient’s a...
Complications
• Cataract development and loss of
  vision possible from scleral nodules
• Rheumatoid nodules can ulcerate,...
Complications
• Bone destruction from nodules in the
  vertebral bodies
• Cardiopulmonary effects later in the
  disease
 ...
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4 Rheumatoid Arthriis 2010

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4 Rheumatoid Arthriis 2010

  1. 1. Rheumatoid Arthritis (RA) • A chronic, systemic disease characterized by inflammation of connective tissue in the synovial joints • Typically have periods of remission and exacerbation
  2. 2. Rheumatoid Arthritis (RA) • Affects all ethnic groups • Can occur at any time of life • Incidence ↑ with age • Women are affected 2-3 times more frequently then men • Smoking appears to be a link
  3. 3. Etiology and Pathophysiology • Cause of RA is unknown • No infectious agent has been cultured from blood and synovial tissue or fluid • Autoimmune etiology is currently the most widely accepted
  4. 4. Etiology and Pathophysiology • Autoimmunity – Changes begin when a susceptible host experiences an initial immune response to an antigen – Antigen triggers the formation of an abnormal immunoglobulin G (IgG)
  5. 5. Etiology and Pathophysiology • Autoimmunity – RA is characterized by the presence of autoantibodies (rheumatoid factor [RF]) – RF and IgG form immune complexes that initially deposit on synovial membranes or superficial articular cartilage in the joints – An inflammatory response results
  6. 6. Etiology and Pathophysiology • Autoimmunity – Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding • Cartilage • Ligaments • Tendons • Joint capsule
  7. 7. Etiology and Pathophysiology • Autoimmunity – Pannus (a proliferation of synovial tissue) forms within the joint – Eventually covers and erodes the entire surface of the articular cartilage – Pannus scars and shortens supporting structures • Tendons • Ligaments – Causing joint laxity, subluxation, and contracture
  8. 8. A. Synovial swelling & fluid accululation B. Pannus, eroded articular cartilage & joint space narrowing
  9. 9. Joint space narrowing and osteophytes
  10. 10. Etiology and Pathophysiology • Genetic factors – Genetic predisposition appears to be important in the development of RA – Strongest evidence for a familial influence is the ↑ occurrence of certain human leukocyte antigens (HLA)
  11. 11. Clinical Manifestations Joints • Onset of RA is typically insidious • Nonspecific manifestations may precede the onset of arthritic complaints – Fatigue – Anorexia – Weight loss – Generalized stiffness
  12. 12. Clinical Manifestations Joints • Stiffness becomes more localized in the following weeks to months • Some patients report a history of precipitating stressful events – Research has been unable to correlate such events directly with the onset of RA
  13. 13. Clinical Manifestations Joints • Specific joint involvement – Pain – Stiffness – Limitation of motion – Signs of inflammation • Heat • Swelling • Tenderness
  14. 14. Clinical Manifestations Joints • Joint symptoms occur symmetrically and frequently – Small joints of the hands and feet – Larger peripheral joints • Wrists, elbows, shoulders, knees, hips, ankles, and jaw – Cervical spine
  15. 15. Clinical Manifestations Joints • Often experience joint stiffness after periods of inactivity • Morning stiffness may last from 60 minutes to several hours or more • Joints become tender, painful, and warm to the touch
  16. 16. Clinical Manifestations Joints • Joint pain – ↑ with motion – Varies in intensity – May not be proportional to the degree of inflammation – Tenosynovitis • Difficult for patients to grasp objects
  17. 17. Clinical Manifestations Joints • Inflammation and fibrosis of the joint capsule and supporting structures may lead to deformity and disability • Subluxation – Atrophy of muscles and destruction of tendons around the joint cause one articular surface to slip past the other
  18. 18. Early Rheumatoid Athritis
  19. 19. Advanced Rheumatoid Athritis
  20. 20. Deformities of RA Fig. 63-4
  21. 21. Clinical Manifestations Extraarticular Manifestations • RA can affect nearly every system of the body • Three most common – Rheumatoid nodules – Sjögren syndrome – Felty syndrome
  22. 22. Extraarticular Manifestations of RA Fig. 63-5
  23. 23. Rheumatoid Nodules • Develop in 25% of all patients with RA • Usually have high titers of RF • Appear as firm, nontender, granuloma-type masses • Usually over the extensor surfaces of joints such as fingers and elbows
  24. 24. Rheumatoid Nodules • Nodules at the base of the spine and back of the head are common in older adults • Develop insidiously • Can persist or regress spontaneously • Usually not removed
  25. 25. Rheumatoid Nodules
  26. 26. Rheumatoid Nodules - elbow
  27. 27. Rheumatoid Nodules
  28. 28. Complications • Flexion contractures and hand deformities – Cause diminished grasp strength – Affect the patient’s ability to perform self-care tasks
  29. 29. Complications • Cataract development and loss of vision possible from scleral nodules • Rheumatoid nodules can ulcerate, similar to pressure ulcers • Hoarseness from nodules on the vocal cords
  30. 30. Complications • Bone destruction from nodules in the vertebral bodies • Cardiopulmonary effects later in the disease – Pleurisy, pleural effusion, pericarditis, pericardial effusion, cardiomyopathy • Carpal tunnel syndrome
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