Rheumatic Diseases | Rheumatoid Arthritis
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This document provides an overview of rheumatoid arthritis (RA) and evaluating patients with rheumatic diseases. It discusses evaluating joint swelling based on distribution, acute vs chronic symptoms, and evidence of systemic inflammation. Common tests in rheumatology like joint aspiration and antibodies are also outlined. RA is introduced as a chronic inflammatory disease affecting the synovium. Diagnostic criteria, manifestations, associated syndromes, laboratory findings, and treatment options for RA are summarized. Complications of RA like atlantoaxial subluxation are also mentioned.
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Rheumatic Diseases | Rheumatoid Arthritis
- 1. Rheumatic Diseases-An Introduction and Evaluation Dr. Subhash Thakur MD (PGIMER, Chandigarh) MBBS 3rd Year, Lecture, 2nd June 2021 @ CMC, Bharatpur, Nepal And Rheumatoid Arthritis
- 2. Contents • Evaluating a Patient with Arthritis and Rheumatic Disease • Tests in Rheumatology • Rheumatoid Arthritis • Introduction • Clinical Features & manifestations • Diagnostic Criteria • Associated Syndromes • Laboratory • Treatment • Complications
- 3. Evaluating a Patient With Arthritis and Rheumatic Disease Evaluation of Joint Swelling 1. Distribution 2. Acute Vs Chronic 3. Symptoms beyond Arthritis (Systemic) 4. Joint Inflammation
- 4. 1. Distribution A. Polyarticular Symmetric B. Monoarticular C. Oligoarticular Asymmetric D.Migratory
- 5. A. Polyarticular Symmetric • Rheumatoid Disease • Systemic Lupus Erythematosus • Viral Infections: Hepatitis B, EBV, Parvo B-19
- 6. B. Monoarticular • Osteoarthritis (OA) • Septic Arthritis • Gout or Pseudogout
- 7. C. Oligoarticular Asymmetric • Spondyloarthropathies • Ankylosing Spondylitis • Psoriatic Arthritis etc
- 8. D. Migratory • Lyme Disease • Gonococcall eg. Disease • Rheumatic Fever
- 9. 2. Acute Vs Chronic • Patient: Monoarthritis • Symptomatic for months to years: OA • Few days: Crystal induced arthropathy or Septic Arthritis
- 10. 3. Evidence of Systemic Symptoms • SLE • Skin, Lung, CNS, Blood, Kidney • Sjogren’s • Sicca, Parotid enlargement • Systemic Sclerosis • Skin, Raynaud’s • Wegner’s • Sinusitis, rhinitis, Lung, Kidney • OA • Paucity of systemic Symptoms
- 11. 4. Evidence of Inflammation • Erythema, warmth • Joint Stiffness>1 hour • Elevated ESR and CRP • Elevated white Cells in the aspirate • Eg. RA Vs OA
- 12. Eg. A 62 years old male with right Knee pain • For 5 years, hx of football playing, crushly sound, no stiffness • Arthrocentesis need to be done to rule out Septic Arthritis • For 1 day: Monoarticular Arthritis: D/d Crystal Induced or Septic Arthritis • D/d: OA, X-ray and treat accordingly
- 13. 2. 24 years old female, symmetric wrist, MCPs, PIPs, swelling and pain • To look for systemic Symptoms • To look for viral titers • To look for RF • Polyarticular Symmetric
- 14. 3. 32 years male, right knee swelling, few days ago he had right wrist swelling and pain that has resolved now • Migratory • Lyme • Gonococcal • Rheumatic Fever
- 15. 4. 29 years male, right knee and left hip pain for may years. His other problem is chronic back pain and stiffness •Oligo articular Asymmetric •Ankylosing Spondylitis
- 17. Tests In Rheumatology A. Joint Aspiration B. Anti-nuclear Antibodies (ANAs) C. Rheumatoid Factor (RF) D.ANCA (Anti Nuclear Cytoplasmic Antibody) E. Antiphospholipid Antibodies
- 18. A. Joint Aspiration • When do we do a joint Aspiration Ans: Always, when concerned about septic arthritis, Acute Monoarthritis • Contraindications: • Cellulitis • Bleeding diathesis • What Tests Do we Get? Ans: 3 Cs and gram stain: Cells, Culture, Crystals
- 19. Stratification Diseases WBCs Crystals/Polarization DJD, Traumatic <2000 Negative Inflammatory Rheumatoid Arthritis Gout CPPD 5000-50000 Negative for RA Needle shaped or negative birefringent Rhombdoid or Positive birefringent Septic >50000 Negative Gram Stain and Culture: Usually Negative
- 20. B. Anti-nuclear Antibodies (ANAs) • Antibody against nuclear structures • Common in SLE, Sjogren’s, Scleroderma • May be seen in normal patients • Pattern: Rim, Nucleolar • Subsets: Ds DNA antibodies, SM ab’s, anti histone ab’s
- 21. Patterns Peripheral (Rim) SLE Diffuse Non – Specific Speckled Non – Specific Centromere CREST Nucleolar Systemic Sclerosis
- 22. Specific Antibodies Anti ds DNA (native DNA) SLE only (60%), an indicator of disease activity and Lupus nephritis Anti – SM SLE Only (25-30%) Anti histone Drug induced Lupus (95%) Anti-Ro (SSA) Neonatal Lupus, Sjogren’s and in the 3% of ANA – lupus Anti – LA (SSB) Sjogren’s Anti-Centromere CREST Anti RNP 100% mixed Connective Tissue Disorder
- 23. C. Rheumatoid Factor (RF) • Usually positive in RA • RF negative RA (20-30%) • Very high RF: poor prognosis • RF positive in other diseases: Osteomyelitis, Tuberculosis, Subacute Endocarditis
- 24. D. ANCA • Wegner’s: C-ANCA + • PAN, IBD: P-ANCA +
- 25. E. Antiphospholipid Antibodies • Lupus Anticoagulant • Anticardiolipin Antibodies • Elevated PTT (Lab phenomenon), False+ VDRL • Hypercoaguable State : Venous + Arterial • Spontaneous abortion in otherwise healthy women • Treatment: Anticoagulate if Symptomatic
- 27. Rheumatoid Arthritis • Rheumatoid Arthritis • Introduction • Clinical Features & manifestations • Diagnostic Criteria • Associated Syndromes • Laboratory • Treatment • Complications
- 28. Clinical Scenario • A 26 years old female, presents with a 3 week history of joint swelling and stiffness, PIPs, MCPs and wrists are involved symmetrically, which you confirm on exam. Stiffness in the morning is > 2 hrs. She also has fatigue and low grade fever. She has no back pain or DIP involvement. Ans: Polyarticular Symmetric: RA Vs SLE Vs Viral Infections
- 29. Rheumatoid Arthritis • Chronic Inflammatory, multisystem disease • Main focus: Synovium • Hall mark: Inflammatory synovitis in a symmetric distribution • Bone erosions, deformities • Predominant Cells: T-Lymphocytes • Pro-Inflammatory Cytokines that mediate inflammation: TNF-α, IL-1, IL-6
- 30. Q. What Rheumatic Disease is uncommon in HIV ? • RA • Decreased Helper T-Cells Q. A patient has RA and all of sudden his RA gets better? • HIV
- 31. Diagnostic Criteria • Morning Stiffness (>1 hr) for 6 weeks • Swelling of wrists, MCPs, PIP For 6 weeks • Swelling of 3 joints for 6 weeks • Symmetric joint swelling for 6 weeks • Joint erosions on X-rays • RF+ • Rheumatoid Nodules
- 33. Articular • Radial deviation of the wrist and ulnar deviation of the digits • Boutonniere Deformity • PIP: Flexed • DIP: Extended Its not that DIP joint is involved its actually tendon arthropathy.
- 34. • Swan Neck Deformity • PIP: Extended • DIP: Flexed Its not that DIP joint is involved its actually tendon arthropathy.
- 35. Extra Articular • Are not as common as in Lupus • Rheumatoid Nodules • Focal Vasculitis • 20-30% RA • Occur in area of mechanical stress: • Olecranon, Occiput, Achilles tendon • Methotrexate may cause a flair
- 36. Associated Syndromes • Felty’s Syndromes • Triad of : RA + Splenomegaly + Neutropenia (Infections)
- 37. • Caplan Syndrome • Pneumoconiosis + RA • Rheumatoid nodules in Lung
- 38. Laboratory • RF • Anaemia: ACD, 1st rule out IDA with Iron Profile (S. iron, ferritin and TIBC) • ESR: Elevated • X-rays: erosions or periosteal depletion • Synovial Fluid Analysis: Cells (5000-50000) • Gm Stain - • Culture - • Crystal -
- 39. Treatment • NSAIDs • COX-2 Inhibitors • Corticosteroids • Methotrexate • TNF Inhibitors
- 40. NSAIDs • One is not better than other. All are same
- 41. COX-2 Inhibitors • a/w stroke, CVA • Supposed to be more protective for peptic ulcer
- 42. Methotrexate • On Methotrexate: Check CBC: to rule out myelosuppression and Liver Enzymes • Every 2-3 weeks • Unless very mild, start on MTX directly • Especially in people with poor prognosis • Requires few weeks to month, till then NSAIDs, Steroids
- 43. Dosing • Initial: 7.5 mg PO/IV/IM as a single weekly dose, OR • 2.5 mg PO q12hr for 3 sequential doses per week folic acid or folinic acid to reduce the risk of methotrexate adverse reactions
- 45. TNF Inhibitors • In resistant RA • Infliximab • Adalimumab • Etanercept Caution: Tb Reactivation: check with PPD
- 46. Complications • Atlantoaxial Subluxation: • Atlas (C1) and Axis (C2) involvement • Incidence: 25-80%, if spine gets involved: paraplegia, quadriplegia • Subtle Symptoms: • Neck pain, Occipital (C2 radicular pain) • Paraesthesia of hands and foot • Diagnosis: • X-ray of cervical Spine (open mouth view) Screen for C1 and C2 subluxation before intubation or anaesthesia
- 47. Thank You