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  2. 2. Rheumatoid Arthritis Definition<br />Rheumatoid arthritis is a chronic disease that causes inflammation in the joints and certain other organs throughout the body. It is called an autoimmune disorder. It is believed that the body's immune system accidentally mistakes its own tissues for foreign invaders. The immune system attacks the joints and organs, causing damage.<br />Characterized by:<br />Symmetrical inflammatory polyarthritis<br />Extera-articular involvement<br />Progressive joint damage causing severe disability<br />
  3. 3. Causes of Rheumatoid Arthritis<br /> RA is caused by a combination of genetic and environmental factors that trigger an abnormal immune response. <br /> Possible causes: <br /><ul><li>Genetic factors-Certain genes that play a role in the immune system are associated with RA development.
  4. 4. Defects in the immune system can cause ongoing inflammation.
  5. 5. Environmental factors-Certain infectious agents, such as some viruses or bacteria, may increase susceptibility to RA.
  6. 6. Other factors-Some evidence suggests that hormonal factors may promote RA development in combination with genetic factors and environmental exposure.</li></li></ul><li>Rheumatoid Arthritis Risks<br />It is possible to develop rheumatoid arthritis with or without the risk factors listed below <br /><ul><li>Blood Transfusions ; increased risk of developing rheumatoid arthritis
  7. 7. Age ; can develop at any age, you're most likely to develop the condition between the ages of 25 and 45.
  8. 8. Gender ; Women are to 3 times more likely to develop rheumatoid arthritis than men.
  9. 9. Genetic Factors</li></ul> You are more likely to develop rheumatoid arthritis if there are other people in your family with this condition or with other autoimmune disorders.<br /><ul><li>Ethnic Background</li></ul> You have a greater risk of developing rheumatoid arthritis if you are: <br /><ul><li> White . Weight</li></ul> People who are obese may have an increased risk of developing rheumatoid arthritis.<br /><ul><li>Coffee and Cigarettes</li></ul> Some studies have suggested that there is a connection between drinking coffee and developing rheumatoid arthritis. More work needs to done to confirm this association.<br /><ul><li>Long-term smoking </li></ul> may be a risk factor for the development of rheumatoid arthritis.<br />
  10. 10. Symptoms of Rheumatoid Arthritis<br />Joint symptoms usually involve three or more joints. The most commonly affected joints are the wrists, fingers, knees, feet, and ankles.<br /> Joint symptoms include:<br /><ul><li>Increased pain and stiffness in the morning and after inactivity
  11. 11. Morning stiffness and pain that lasts more than 30 minutes
  12. 12. Pain and stiffness symmetrically (that is, both feet or both hands are affected, as opposed to only one)
  13. 13. Red, swollen, warm joints
  14. 14. Deformed, misshapen joints.</li></ul>Other symptoms of rheumatoid arthritis include: <br />Intense fatigue, decreased energy <br />Muscle aches <br />Decreased appetite <br />Weight loss <br />Fever and sweats <br />
  15. 15. Depression <br />Problems sleeping <br />Anemia <br />Bumps occurring under the skin (rheumatoid nodules) <br />Inflamed blood vessels <br />Bleeding stomach ulcers <br />Inflammation of the heart's sac ( Pericarditis) <br />Inflammation of the heart muscle ( Myocarditis) <br />Lung problems <br />Eye problems<br />
  16. 16. Pattern of joint involvement:<br /><ul><li>Proximal interphalangeal and metocarpophalangeal joint of fingers
  17. 17. wrist , knee ,ankle and toe
  18. 18. Distal interphalangeal joint spared</li></ul>Deformities:<br />As the disease advances(after months or years) pain , muscle spasm and joint destruction result in limitation of joint movement , joint instability, subluxation(partially dislocation) and deformities <br />Hands<br /><ul><li>Spindling of the fingers (swelling of the metacarpophalangeal joint)
  19. 19. Sublaxation of metacarpophalangeal joint
  20. 20. Swan neck deformity
  21. 21. Button-hole deformity
  22. 22. Z-deformity of thumb
  23. 23. Carpal tunnel syndrome.</li></li></ul><li>Feet<br /><ul><li>Lateral deviation of the toes
  24. 24. Sublaxation of metacarpophalangeal joint</li></ul>Knee<br /><ul><li>Synovial effusion
  25. 25. Valgus and virus deformities</li></ul>D/D from osteoarthritis :<br /> in (OA) the number of joints affected is much less than (RA).<br /> in (RA) distal interphalangeal joint is spared while in (OA) it is characteristically involved.<br />The joint most commonly involved in (OA) are weight bearing e.g.<br /> knee and hip joints.<br />
  26. 26. How to Diagnose Rheumatoid Arthritis<br /> We suspect rheumatoid arthritis after taking a careful history of your symptoms and physical exam will be done<br /> According to The American College of Rheumatology, if you have four of the seven symptoms listed below for more than 6 weeks you are considered to have rheumatoid arthritis: <br /><ul><li> Morning stiffness that lasts over an hour
  27. 27. Arthritis in at least three joints
  28. 28. Arthritis of the joints of the hand
  29. 29. Arthritis on both sides of the body
  30. 30. A positive blood test for rheumatoid factor (RF)
  31. 31. Presence of lumps under the skin, called rheumatoid nodules
  32. 32. X-rays that show signs of rheumatoid arthritis affecting the joints.</li></ul> (With duration of sex weeks or more , diagnosis of RA made with 4 or more criteria )<br />
  33. 33. Test:<br /> your doctor may recommend other tests to confirm the diagnosis or to evaluate whether your internal organs are also involved. Such tests may include the following:<br />Blood tests -A number of blood tests can point to the presence of an autoimmune disorder. These include: <br /><ul><li>Rheumatoid factor
  34. 34. Anti citrullinated peptide antibody (anti cpp)
  35. 35. Erythrocyte sedimentation rate
  36. 36. Antinuclear antibody
  37. 37. C-reactive protein</li></ul>2. Imaging tests -Imaging tests may be used to visualize the internal organs, in order to see whether rheumatoid arthritis has affected them. symptoms. Imaging tests may include: <br /><ul><li>X-rays , CT scans , MRI scans.</li></ul>3 . Arthrocentesis -Removing some joint fluid for laboratory exam may reveal the presence of white blood cells, crystals, or bacteria. This test is most commonly used to exclude other causes of arthritis. <br />
  38. 38. STAGES OF X-RAY PROGRESSION IN RHEUMATOID ARTHRITIS :<br /><ul><li>(1) particular osteoporosis .
  39. 39. (2) loss of articular cartilage resulting in loss of joint space.
  40. 40. (3) Erosions gives mouth-bite appearance on the surface of The affected bone.
  41. 41. (4) Subluxation and Ankylosis.</li></ul> these 4 stages indicate the advancement of the disease process<br />MANAGMENTS :<br /> there are 5 stages in management of RA with ,<br />LOCAL MANAGEMENT include <br /> rest splints<br />Inter-articular corticosteroid injection.<br />SYSTEMIC MANAGEMENT include<br />NON-steroidal anti-inflammatory drugs <br />Simple analgesics<br />Slow acting disease modifying anti-rheumatic dugs e.g.<br /> antimalarial , sulphasalazine , penicillamine<br />
  42. 42. THE 5 STAGES ARE :<br />Stage 1 :<br /><ul><li>Making the diagnosis
  43. 43. Education of the patient and reassured
  44. 44. Joint protection buy physical activity normally.</li></ul>Stage 2 :<br /><ul><li>Symptomatic treatment with NSAIDs and other measures</li></ul>By using aspirin “drug of choice” , rest splints and inter-articular corticosteroid inj. Is indicated in inflammatory joints.<br />Stage 3 :<br /><ul><li>The control of the disease with long-term suppressive drugs
  45. 45. Disease modifying anti-rheumatic drugs , these indicated when s/s of active arthritis have persisted for 3-4 months with adequate optimal doses of NSAID with radiological damage e.g. Antimalarials , sulphasalazine , penicillamine , corticosteroid and methotrexat .</li></ul>Stage 4 :<br /><ul><li>Regular supervision and management of complication.</li></ul>Stage 5 :<br /><ul><li>Rehabilitation of the pt.</li></li></ul><li>EXTRA-ARTICULAR FEATURES:<br />Musculoskeletal :<br /><ul><li>Subcutaneous nodules at the site of pressures.
  46. 46. Bursitis.
  47. 47. Tenosynovitis.
  48. 48. Muscle wasting.</li></ul>Neurological :<br /><ul><li>Carpal tunnel syndrome.
  49. 49. Atlanto-axial subluxation.
  50. 50. Polyneuropathy</li></ul>Ocular :<br /><ul><li>Sjogren”s Syndrome.
  51. 51. Scleritis.
  52. 52. Keratoconjuctivitis.</li></ul>Haematological :<br /><ul><li>Anaemia.
  53. 53. Thrombocytosis.</li></li></ul><li>Pulmonary :<br /><ul><li>Pleural effusion(commonest).
  54. 54. Diffuse fibrosing alveolitis.
  55. 55. Rheumatoid nodules in the lungs.
  56. 56. Calpan”s Syndrome.</li></ul>Cardiac :<br /><ul><li>Pericardial rub
  57. 57. Pericarditis , myocarditis.</li></ul>Lymphatic :<br /><ul><li>Lymphadenopathy.
  58. 58. Splenomegaly.
  59. 59. Felty’s syndrome.</li></ul>Skin<br /><ul><li>Vasculitis.</li>