pathophysiology

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. 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. 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. 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. 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. Etiology and
Pathophysiology
• Autoimmunity
– Joint changes from chronic inflammation
begin when the hypertrophied synovial
membrane invades the surrounding
• Cartilage
• Ligaments
• Tendons
• Joint capsule

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. A. Synovial swelling & fluid accululation
B. Pannus, eroded articular cartilage &
joint space narrowing

9. Joint space narrowing and
osteophytes

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. 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. 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. Clinical Manifestations
Joints
• Specific joint involvement
– Pain
– Stiffness
– Limitation of motion
– Signs of inflammation
• Heat
• Swelling
• Tenderness

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. 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. 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. 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. Early Rheumatoid
Athritis

19. Advanced Rheumatoid
Athritis

20. Deformities of RA
Fig. 63-4

21. Clinical Manifestations
Extraarticular Manifestations
• RA can affect nearly every system of
the body
• Three most common
– Rheumatoid nodules
– Sjögren syndrome
– Felty syndrome

22. Extraarticular Manifestations of RA
Fig. 63-5

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. 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. Rheumatoid Nodules

26. Rheumatoid Nodules -
elbow

27. Rheumatoid Nodules

28. Complications
• Flexion contractures and hand
deformities
– Cause diminished grasp strength
– Affect the patient’s ability to perform
self-care tasks

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. 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