Rheumatoid arthritis is a chronic inflammatory disease that affects the joints, causing swelling and stiffness, eventually resulting in deterioration of bone and cartilage. It is caused by an autoimmune response and is characterized by symmetric inflammation of multiple small joints of the hands and feet. Symptoms progress from early inflammation to joint destruction and deformity if left untreated.

1. Rasha Khamis Al-Dabbagh
5th year IUG medical student

2. • 3% of the population
• : ,3:1
• 4th-5th decade
• Smoking

3. • Unknown
• Multifactorial:
– HLA-DR4
– Some antigen -possibly a virus- sets off
a chain of events culminating in a chronic
inflammatory disorder with abnormal
immunological reactions.
– Autoantibodies “Rheumatoid Factor”

4. • All tissues are affected.
• Stages:
 Stage 1 synovitis :
– Synovial membrane inflammation &
thickening, cell-rich effusion, intact
joints & tendons, reversible.
– S&S: swelling, hotness, tenderness (PIP
& wrists >>> elbows, shoulders, knees,
ankles & feet)

5.  Stage 2 destruction :
– Articular cartilage erode & tendons may
rupture.
– S&S: stiffness & LOM esp. in the
morning, tendon ruptures. Subcutaneous
nodules in 25% (olecranon process).

6.  Stage 3 deformity :
– Articular destruction, capsular stretching,
tendon rupture. Progressive instability &
deformity.
– S&S: severe muscle wasting, painful callosities
under metatarsal heads.
– Deformities :
o Ulnar deviation, MCP subluxation or dislocation,
claw feet, atlantoaxial sublaxation
o Swan neck deformity
o Button hole deformity
o Z deformity of the thumb
o Carpal tunnel syndrome

8. • Rheumatoid nodules: in 25%, over
bony prominences, tendons, sclera,
viscera.
• Lymphadenopathy
• Vasculitis
• Muscle weakness
• Visceral disease (lungs, heart,
kidneys, brain & GIT)

10. Stage 1:
– Soft tissue swelling, periarticular
osoteoporosis.
Stage 2:
– Joint space narrowing, marginal bony
erosions (esp. wrists & PIP).
Stage 3:
– Articular destruction, joint deformity.

12. • ESR & CRP in active phase.
• RF in 80%, used in assessing
prognosis.
• ANA in 30-40%.

13. • Minimal criteria:
– Bilateral symmetrical polyarthritis.
– Involving proximal joints of hands or
feet.
– At least 6 weeks.
• Subcutaneous nodules, periarticular
erosins on x-ray confirm the
diagnosis.

14. • Seronegative polyarthritis
• Ankylosing spondylitis
• Reiter‟s disease
• Polyarticular gout
• Polyarticular osteoarthritis
• Polymyalgia rheumatica

15. • 80 % Classical „periodic‟ course:
relapsing & remitting.
• 5% Rapidly progressive: with visceral
involvement.
• 10% -in men over 55yrs- explosive onset
after which it tends to subside & follow
a mild course.
• In few patients only 1-2 attacks then
disappears.

16. • Infection (septic arthritis)
• Tendon rupture esp. wrist
• Joint line rupture
• Secondary osteoarthritis

17. • Rest
• Exercise
• Splintage & orthotic devices
• Rehabilitation
• Physiotherapy

18. • NSAIDS
• Low-dose corticosteroids
• DMARD e.g gold & pencillinamine
• Surgical:
– Operative Tx e.g. synovectomy, tendon
repair or joint stabilization
– Reconstructive surgery
– Arthrodesis, osteotomy, arthroplasty

20. • Chronic inflammatory disease
• 0.2% in Western Europe
• >
• 15-25 years

21. • Multifactorial:
– HLA-B27
– Trigger e.g. GU or GI infection

22. • Three characteristic lesions:
1. Synovitis of synovial joints.
2. Inflammation of fibro-osseous
junctions of fibrous joints, tendons &
ligaments (enthesopathy).
3. Ossification across the peripheries of
intervertebral discs.

23. • Fairly constant sequence:
Inflammation > granulation tissue >
cartilage or bone erosion >
replacement by fibrous tissue >
fibrous tissue ossification > ankylosis

24. • Mainly in spine & sacroiliac joints, sometimes
hips & shoulders, rarely peripheral joints.
• Persistent backache & stiffness worse in
morning or after inactivity.
• LOM of spine, extension being earliest &
most severe.
• In > 10% onset in a peripheral joint.
• Atypical onset is more common in .

25. Fingertips-to-floor Chest expansion
Wall test distance

26. • 6 A‟s:
– Anterior uveitis
– Atlanto-axial sublaxation
– Apical lung fibrosis
– Aortitis, aortic regurge & AV block
– Amyloidosis
– Achilles tendonitis

27. • Fuzziness or frank erosion of
sacroiliac joints, later sclerosis,
eventually ankylosis.
• Intervertebral discs ossification
causes bony bridges „syndesmophytes‟,
if several levels are involved bamboo
spine .

29. • ESR in active phase
• HLA-B27 in 90%

30. • Other sero-ve spondylarthropathies
• Ankylosing hyperostosis „Forestier‟s
disease‟:
– Mild or nonexistent S&S.
– Incidental x-rays show widespread ossification
of ligaments & tendon insertions.
• Mechanical back pain:
– in young adults
– Muscle strains, facet joint dysfunction,
discogenic disorders.

31. • Medical:
– Exercise
– Postural training to prevent deformity
– Analgesics & NSAIDs
• Surgical:
– Joint replacement for hip stiffness
– Vertebral osteotomy for severe flexion
deformity

33. • Common features:
1. Characteristic spondylitis & sacroiliitis.
2. HLA-B27 association.
3. Familial aggregation.
4. Familial overlap with members having one
disorder & relatives having another.
• Includes:
– Ankylosing spondylitis
– Psoriatic arthritis
– Reiter‟s disease
– IBD associated arthritis

34. • Psoriatic arthritis ≠ RA + Psoriasis
• : equal
• HLA-B27 in 60%
• S&S:
– Mainly in IP joints of fingers & toes.
– Not as symmetrical as in RA.
– Arthritis mutilans in severe cases.
– ¼ develop AS-like sacroiliac & vertebral
changes.

35. • Treatment:
– Judicious splintage to prevent deformity.
– Topical skin preparations.
– NSAIDs.
– Surgery for unstable joints.

36. • Triad: polyarthritis, conjunctivitis &
non-specific urethritis.
•Synoivitis is due to abnormal
immune response to infection
or its products elsewhere
urogenital or bowel
infection
 Lymphogranuloma venereum
& Chlamydia trachomatis in
GUT.
 Shigella, Salmonella &
Yersinia enterocolitica in GIT.

37. • Hx of GU infection or diarrhea.
• Mainly large joints, knee & ankle.
• Tenosynovitis & plantar fasciitis are common
• Sacroiliitis & spondylitis causing backache &
stiffness occur at some stage.
• „Self-limiting‟ but 80% have symptoms for many
years.
• Ocular lesions: conjunctivitis,
episcleritis & uveitis.

38. • Normal at first
• Erosive arthritis after many months.
• AS-like sacroiliac & vertebral
changes.

39. • HLA-B27 in 75% .
• ESR in active phase.
• Urethral fluids, faeces or Ab test
may indicate the organism.

40. • Directed at the GU or GI infection
“Antibiotics”.
• Chlamydia: daily tetracycline for 6
months.
• Local:
– Rest & splintage in severe arthritis.
– Anti-inflammatory agents.

42. • Noninfective inflammatory joint
disease > 3 months in children < 16
years.
• : equal.
• 1 per 1000 children.
• Multifactorial: Genetic
predisposition + abnormal
immune response to some antigen.
• RF is -ve

43. 1. Systemic JCA:
– Age < 3 years.
– Onset: intermittent fever, rashes &
malaise.
– May be lymphadenopathy,
hepatosplenomegaly.
– Joint swelling after weeks-months.

44. 2. Pauciarticular JCA:
– Commonest form.
– Age < 6 years, girls.
– Few joints, no systemic illness.
– Pain & swelling in medium-sized joints.
– Chronic iridocyclitis in 50%.

45. 3. Polyarticular sero+ve JCA:
– Older girls.
– Resembles RA juvenile RA .
– RF is +ve.
4. Sero-ve spondarthritis:
– Older boys.
– Sacroiliitis & spondyliitis.
– May be hips & knees.
– HLA-B27 often +ve juvenile AS .

47. • Stiffness , sometimes permanent.
• Growth defects & retardation.
• Iridocyclitis , may lead to blindness.
• Amyloidosis, can be fatal.

48. • General: similar to RA
• Local: prevent stiffness & deformity
– Night splints.
– Prone lying for some period daily to prevent
flexion contracture of hips.
– Active exercises.
• Surgical: for painful eroded joints
– Custom-designed arthroplasty of hip & knee.
– Arthrodesis of wrist & ankle.

49. • Most recover with moderate LOM.
• 5-10% severely crippled esp. JRA.
• 3% mortality :
– Overwhelming infection,
– Renal failure due to amyloidosis.

51. • Auto-immune disorders.
• Like RA triggered by viral infection in
genetically predisposed individuals.
• SLE:
– Progressive joint deformity is unusual.
– A curious complication is avascular
necrosis usually in femoral head.

52. • A descriptive term for a condition in
which patients complain of pain &
tenderness in muscles & other soft
tissues around the back of the neck &
shoulders, lower back & upper buttocks.
• No pathology in affected tissues.
• Depression & anxiety.

53. • Criteria:
– Widespread pain in all four body
quadrants.
– At least 9 pairs of tender points in
physical examination.

54. • Cause:
– unknown
– Suggested theories:
• Abnormality of ”sensory processing” i.e. ”low pain
threshold”.
• Activation of stress responses by sudden
accidents or traumatic life events.
• Tx:
– Physiotherapy & daily exercise.
– Injections into painful areas.
– Psychotherapy.