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- 2. Brief History • JS • 24 F • Sitio Bato, Tampakan, South Cotabato • Joint pain for 1 year (Wrists, finger, hips, elbow) • Joint pains upon awakening in the morning, decreased ROM associated with on and off fever (Tmax undocumented). Sought consultation, was given Celecoxib 200mg/tab BID. Relieved but reocurrence of symptoms noted.
- 3. Brief History Past Medical History: No previous admissions, no surgeries, no BA, (-) DM, (-) HPN, (-) PTB, (-) Hepatitis B Family History: (-) History of rheumatic and joint diseases ROS: (+) on and off Fever, (+) Joint Paints and limitations in ROM Physical Exam: (+)Symmetrical joint deformity (Fingers, Elbow),(+) Gait abnormality
- 4. Labs • ASO: 517 IU/ML (H) • CRP: 7 mg/L (H) • ESR: 29mm/hr (H)
- 5. • Chronic inflammatory disease of unknown etiology • Characterized by a symmetric polyarthritis and is the most common form of chronic inflammatory arthritis. • Results in articular cartilage and bone destruction and functional disability • Systemic disease: fatigue, subcutaneous nodules, lung involvement, pericarditis, peripheral neuropathy, vasculitis, and hematologic abnormalities. Rheumatoid Arthritis
- 6. • 25 and 55 years of age, plateaus until the age of 75, then decreases. • Early morning joint stiffness lasting >1 hour • Eases with physical activity • Involved joints are typically the small joints of the hands and feet • Symmetrical polyarthritis CLINICAL FEATURES • Initial pattern of joint involvement may be monoarticular, oligoarticular (≤4 joints), or polyarticular (>5 joints), usually in a symmetric distribution • Once the disease process of RA is established: Wrists, elbows and metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints- most frequently involved joints.
- 8. • Coexistent osteoarthritis; Distal interphalangeal (DIP) joint involvement may occur • Flexor tendon tenosynovitis: hallmark of RA decreased range of motion • Reduced grip strength CLINICAL FEATURES • Initial pattern of joint involvement may be monoarticular, oligoarticular (≤4 joints), or polyarticular (>5 joints), usually in a symmetric distribution • Once the disease process of RA is established: Wrists and metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints- most frequently involved joints.
- 9. • Hyperextension of the PIP joint with flexion of the DIP joint (“swan-neck deformity”) • Flexion of the PIP joint with hyperextension of the DIP joint (“boutonnière deformity”) • Subluxation of the first MCP joint with hyperextension of the first interphalangeal (IP) joint (“Z-line deformity”) * Result from damage to the tendons, joint capsule, and other soft tissues in these small joints.
- 11. RISK FACTORS
- 12. 3 Patient’s number of Joint Involvement: 1 hip joint 2 elbow joints 2 Patellar joints 6 interphalangeal joint ---- Abnormal CRP, ESR ---- > 6 weeks duration
- 13. Laboratory Testing Diagnosis CRP ESR Rheumatoid Factor Anti-citrullinated pe Pre-Treatment and co-morbidity screening: • CBC • Renal Profile • FBS • Lipid profile • Liver fuinction test • Hepatitis screening • HIV screening Treatment Disease Activity monitoring • LFT • ESR • CRP Pre-biologic therapy • Hepa B • HIV • Immunoglobulin G, A, M (Prior to Rituximab)
- 14. LABORATORY FEATURES • Elevated ESR and CRP • Approximately 30% of patients with RA test positive for antinuclear antibodies (ANAs) • Some sera from some patients contain antineutrophil cytoplasmic antibodies (ANCAs; particularly p-ANCAs)
- 15. SYNOVIAL FLUID ANALYSIS • Synovial fluid white blood cell (WBC) counts: 5000 and 50,000 WBC/μL
- 16. JOINT IMAGING Plain x-ray • common imaging modality • Limited to visualization of the bony structures and inferences about the state of the articular cartilage based on the amount of joint space narrowing • Initial radiographic finding is periarticular osteopenia.
- 18. JOINT IMAGING MRI and ultrasound • Detects changes in the soft tissues such as synovitis, tenosynovitis, and effusions • Greater sensitivity for identifying bony abnormalities A. active synovitis at the mid-carpal joint with enhancing synovium adjacent to the scaphoid (wide arrow), an erosion within the capitate (thin arrow) and extensive bone oedema within the lunate and opposite region of the distal radius (circle) B.E rosion within the capitate (arrow) and a new erosion within the distal radius at the site of previous bone oedema (arrow), but no bone oedema within the lunate (circle) and much less synovitis at the carpal joints.
- 19. Diagnosis
- 21. Goals: • Pain relief and control of inflammation • Preservation of joint function • Minimizing complications
- 23. NSAIDS • Core of RA therapy • Exhibit both analgesic and anti-inflammatory properties • Anti-inflammatory effects of NSAIDs derive from their ability to nonselectively inhibit cyclooxygenase (COX)-1 and COX-2. • Side effects:Gastritis,peptic ulcer disease,as impairment of renal function
- 24. GLUCOCORTICOIDS • Administered in low to moderate doses to achieve rapid disease control before the onset of fully effective DMARD therapy, which often takes several weeks or even months: (5–10 mg Once daily) • 1- to 2-week burst of glucocorticoids may be prescribed for the management of acute disease flares • Side effects and risk: Osteoporosis, PUD,immunosupression
- 26. DMARDS(Disease-modifying antirheumatic drugs ) • hydroxychloroquine, sulfasalazine, methotrexate, and leflunomide • Methotrexate is the DMARD of choice for the treatment of RA and is the anchor drug for most combination therapies
- 29. PHYSICAL ACTIVITY AND ASSISTIVE DEVICES • All patients with RA should receive a prescription for exercise and physical activity • Dynamic strength training, community-based comprehensive physical therapy, and physical-activity coaching (emphasizing achieving 150 min of moderate-to-vigorous physical activity per week) • Foot orthotics for painful valgus deformity decrease foot pain and may reduce disability and functional limitations.
- 30. SURGERY • Arthrodesis and total wrist arthroplasty are reserved for patients with severe disease who have substantial pain and functional impairment
- 31. Sources 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
Editor's Notes
- Metacarpophalangeal joint swelling and subluxation
- weight loss, fever, fatigue, malaise, depression, and in the most severe cases, cachexia; they generally reflect a high degree of inflammation and may even precede the onset of joint symptoms. In general, the presence of a fever of >38.3°C (101°F) at any time during the clinical course should raise suspicion of systemic vasculitis (see below) or infection. Subcutaneous nodules- generally firm; nontender; and adherent to periosteum, tendons, or bursae; they develop in areas of the skeleton subject to repeated trauma or irritation such as the forearm, sacral prominences, and Achilles tendon SJÖGREN’S SYNDROME- defined by the presence of either keratoconjunctivitis sicca (dry eyes) or xerostomia (dry mouth) in association with another connective tissue disease PULMONARY- most common pulmonary manifestation of RA, may produce pleuritic chest pain and dyspnea Pulmonary nodules are also common in patients with RA and may be solitary or multiple CARDIAC- most frequent site of cardiac involvement in RA is the pericardium.Cardiomyopathy, another clinically important manifestation of RA, may result from necrotizing or granulomatous myocarditis, coronary artery disease, or diastolic dysfunction, regurgitation is the most common valvular abnormality in RA VASCULITIS- typically occurs in patients with long-standing disease, a positive test for serum RF or anti–cyclic citrullinated peptide (CCP) antibodies, and hypocomplementemia, cutaneous signs vary and include petechiae, purpura, digital infarcts, gangrene, livedo reticularis, and in severe cases large, painful lower extremity ulcerations. HEMATOLOGIC- normochromic, normocytic anemia often develops in patients with RA and is the most common hematologic abnormality. Felty’s syndrome: neutropenia, splenomegaly, and nodular RA The most common cause of death in patients with RA is cardiovascular disease
- active synovitis at the mid-carpal joint with enhancing synovium adjacent to the scaphoid (wide arrow), an erosion within the capitate (thin arrow) and extensive bone oedema within the lunate and opposite region of the distal radius (circle)