For the Final MBBS student

1. ““He who studies medicine without booksHe who studies medicine without books
sails an uncharted sea, but he who studiessails an uncharted sea, but he who studies
medicine without patients does not go to seamedicine without patients does not go to sea
at all.”at all.”
- Sir William Osler- Sir William Osler

2. Rheumatoid ArthritisRheumatoid Arthritis

3. Rheumatoid ArthritisRheumatoid Arthritis
 It is a chronic systemic inflammatory disease ofIt is a chronic systemic inflammatory disease of
unknown etiologyunknown etiology
 Primarily affects the peripheral joints in aPrimarily affects the peripheral joints in a
symmetrical mannersymmetrical manner
 Prevalence 1-2%Prevalence 1-2%
 Female : Male ratio 3:1Female : Male ratio 3:1
 Usual age of onset 20-40 years thoughUsual age of onset 20-40 years though
individuals of any age group may be affectedindividuals of any age group may be affected

4.  Pathologic findingPathologic finding: chronic synovitis with: chronic synovitis with pannuspannus
(exuberant synovial tissue) formation. The(exuberant synovial tissue) formation. The
pannus erodes cartilage, bone, ligament andpannus erodes cartilage, bone, ligament and
tendons.tendons.
 In the acute phase, effusion and otherIn the acute phase, effusion and other
manifestations of inflammation are evident; inmanifestations of inflammation are evident; in
the later stages ankylosis of the joint may set in.the later stages ankylosis of the joint may set in.
 In both the acute and chronic phase, there mayIn both the acute and chronic phase, there may
be widespread inflammation of the tissuesbe widespread inflammation of the tissues
around the joint that can lead to significant jointaround the joint that can lead to significant joint
destruction.destruction.

5. Rheumatoid ArthritisRheumatoid Arthritis
 Clinical presentationClinical presentation
– usually presents insidiously;usually presents insidiously;
– prodromal syndrome of malaise, weight lossprodromal syndrome of malaise, weight loss
and vague periarticular pain and stiffness mayand vague periarticular pain and stiffness may
be seenbe seen
– less commonly, the onset is acute, triggeredless commonly, the onset is acute, triggered
by a stressful situation such as infection,by a stressful situation such as infection,
trauma, emotional strain or in the postpartumtrauma, emotional strain or in the postpartum
period.period.

6. Joint involvementJoint involvement
-is characteristically symmetric with associated stiffness,-is characteristically symmetric with associated stiffness,
warmth, tenderness and painwarmth, tenderness and pain
-the stiffness is characteristically worse in the morning-the stiffness is characteristically worse in the morning
and improves during the day. The stiffness may recurand improves during the day. The stiffness may recur
especially after strenuous activity.especially after strenuous activity.
-the usual joints affected by rheumatoid arthritis are the-the usual joints affected by rheumatoid arthritis are the
metacarpophalangeal jts, the PIP jts, the wrists, knees,metacarpophalangeal jts, the PIP jts, the wrists, knees,
ankles and toes.ankles and toes.
-Entrapment syndromes may occur especially carpal-Entrapment syndromes may occur especially carpal
tunnel syndrometunnel syndrome

7.  Deformities can occur after months to years,Deformities can occur after months to years,
the most common being:the most common being:
– ulnar deviationulnar deviation of the fingersof the fingers
– swan neck deformityswan neck deformity, which is hyperextension of the, which is hyperextension of the
proximal interphalangeal joint and flexion of the distalproximal interphalangeal joint and flexion of the distal
interphalangeal jointinterphalangeal joint
– boutonniere deformityboutonniere deformity, which is flexion of the proximal, which is flexion of the proximal
interphalangeal joint and extension of the distalinterphalangeal joint and extension of the distal
interphalangeal jointinterphalangeal joint
– valgus deformityvalgus deformity of the kneeof the knee

11. Rheumatoid ArthritisRheumatoid Arthritis
Systemic involvementSystemic involvement::
 20% of patients with rheumatoid arthritis will20% of patients with rheumatoid arthritis will
havehave subcutaneous nodulessubcutaneous nodules, usually seen over, usually seen over
bony prominences but also observed in bursabony prominences but also observed in bursa
and tendon sheaths; these nearly always occurand tendon sheaths; these nearly always occur
in seropositive patients as do most other extra-in seropositive patients as do most other extra-
articular manifestationsarticular manifestations
 splenomegalysplenomegaly andand lymphadenopathylymphadenopathy can occurcan occur
 low grade fever, anorexia, weight loss, fatiguelow grade fever, anorexia, weight loss, fatigue
and weakness can occurand weakness can occur

12.  Dryness of the eyes, mouth and other mucusDryness of the eyes, mouth and other mucus
membranes is found, especially in advancedmembranes is found, especially in advanced
diseasedisease
 Pericarditis and pleuritis can occur but arePericarditis and pleuritis can occur but are
usually clinically silentusually clinically silent
 aortitis can occur as a late complication, usuallyaortitis can occur as a late complication, usually
associated with vasculitis; rupture of the aorticassociated with vasculitis; rupture of the aortic
valve cusp can lead to aortic regurgitationvalve cusp can lead to aortic regurgitation

13. Rheumatoid ArthritisRheumatoid Arthritis
LAB TESTSLAB TESTS
1) Detection of auto-antibodies:1) Detection of auto-antibodies:
– Rheumatoid factor (anti-globulin IgM antibody)Rheumatoid factor (anti-globulin IgM antibody)
 RF is present in approximately 60-80% of patients with RARF is present in approximately 60-80% of patients with RA
over the course of their disease.over the course of their disease.
 RF values fluctuate somewhat with disease activity.RF values fluctuate somewhat with disease activity.
 RF may also be present in SLE and systemic sclerosis.RF may also be present in SLE and systemic sclerosis.
Marker for autoimmune activity.Marker for autoimmune activity.
– Antinuclear antibodies: These are present inAntinuclear antibodies: These are present in
approximately 40% of patients with RA.approximately 40% of patients with RA.
– Newer antibodies (anti-RA33, anti-CCP)Newer antibodies (anti-RA33, anti-CCP)

14. 2) The ESR is elevated both in the acute and chronic2) The ESR is elevated both in the acute and chronic
phases of the diseasephases of the disease
3) A moderate anemia is often present which is usually3) A moderate anemia is often present which is usually
hypochromic normocytichypochromic normocytic
4) The white count is normal or slightly increased but4) The white count is normal or slightly increased but
leukopenia may occur, often in presence ofleukopenia may occur, often in presence of
splenomegaly (e.g., Felty’s syndrome)splenomegaly (e.g., Felty’s syndrome)
5) The platelet count is often elevated in proportion to5) The platelet count is often elevated in proportion to
the degree of joint inflammationthe degree of joint inflammation

15. X-rayX-ray
– of all the lab tests, x-ray changes are most specific forof all the lab tests, x-ray changes are most specific for
rheumatoid arthritis. However, they are not sensitiverheumatoid arthritis. However, they are not sensitive
and usually are negative during the first 6 months ofand usually are negative during the first 6 months of
the diseasethe disease
– the earliest changes occur in the wrist or feet andthe earliest changes occur in the wrist or feet and
consist of soft tissue swelling and juxta-articularconsist of soft tissue swelling and juxta-articular
demineralization.demineralization.
– Later, diagnostic changes consisting of joint spaceLater, diagnostic changes consisting of joint space
narrowing and erosions develop.narrowing and erosions develop.
– Diagnostic changes also occur in the cervical spineDiagnostic changes also occur in the cervical spine
with C1-C2 subluxation, but this can take severalwith C1-C2 subluxation, but this can take several
years to develop.years to develop.

16. 0
10
20
30
40
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90
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
East
West
North

17. Criteria for Diagnosis ofCriteria for Diagnosis of
Rheumatoid ArthritisRheumatoid Arthritis
 American College of Rheumatology Revised criteria:American College of Rheumatology Revised criteria:
– At least four of the followingAt least four of the following
 Morning stiffness > 1hourMorning stiffness > 1hour
 Synovitis in three joints simultaneouslySynovitis in three joints simultaneously
 Synovitis in wrist or hand MCP or PIP jointsSynovitis in wrist or hand MCP or PIP joints
 Symmetrical arthritis (same joint areas on bothSymmetrical arthritis (same joint areas on both
sides of the body)sides of the body)
 Rheumatoid nodulesRheumatoid nodules
 Serum rheumatoid factorSerum rheumatoid factor
 Radiographic changes typical of RheumatoidRadiographic changes typical of Rheumatoid
ArthritisArthritis

18. Rheumatoid ArthritisRheumatoid Arthritis
 Differential DiagnosisDifferential Diagnosis
– Pyogenic arthritis: usually monoarticular withPyogenic arthritis: usually monoarticular with
fever and chills.fever and chills.
– Chronic Lyme disease: commonlyChronic Lyme disease: commonly
monoarticular and associated with positivemonoarticular and associated with positive
titerstiters
- Autoimmune connective tissue diseases (eg,- Autoimmune connective tissue diseases (eg,
SLE, SS, MCTD, Sjögren syndrome)SLE, SS, MCTD, Sjögren syndrome)
- Polyarticular Gout, Reactive arthritis.- Polyarticular Gout, Reactive arthritis.

19. Treatment of Rheumatoid ArthritisTreatment of Rheumatoid Arthritis
Goal of treatment -Goal of treatment -
 reduce inflammation and pain,reduce inflammation and pain,
 preservation of function, andpreservation of function, and
 prevention of deformityprevention of deformity..

20. -Nonpharmacologic treatment:-Nonpharmacologic treatment:
o EducationEducation is important in helping patients tois important in helping patients to
understand their disease and to learn how tounderstand their disease and to learn how to
cope with its consequences.cope with its consequences.
o PhysiotherapyPhysiotherapy is initiated to help improve andis initiated to help improve and
sustain range of motion, to increase musclesustain range of motion, to increase muscle
strength, and to reduce pain.strength, and to reduce pain.
o Occupational therapyOccupational therapy is initiated to helpis initiated to help
decrease tension on the joints with possibledecrease tension on the joints with possible
use of specially designed devices.use of specially designed devices.

21. - Pharmacologic Treatment:- Pharmacologic Treatment:
NSAIDs:NSAIDs:
Ibuprofen, Ketoprofen, Piroxicam, Naproxen,Ibuprofen, Ketoprofen, Piroxicam, Naproxen,
DiclofenacDiclofenac
NSAIDs inhibit prostaglandin synthesis byNSAIDs inhibit prostaglandin synthesis by
blocking cyclooxygenase (COX) enzyme, thusblocking cyclooxygenase (COX) enzyme, thus
reducing pain and inflammationreducing pain and inflammation
Do not retard joint destruction.Do not retard joint destruction.

22.  Major side effect of NSAID is gastricMajor side effect of NSAID is gastric
irritation.irritation.
 Older NSAIDs inhibit both COX1 andOlder NSAIDs inhibit both COX1 and
COX2 enzymes. COX1 has protective roleCOX2 enzymes. COX1 has protective role
in gastric mucosa.in gastric mucosa.
 Newer NSAIDs like Celecoxib areNewer NSAIDs like Celecoxib are
selective COX2 inhibitors and thus haveselective COX2 inhibitors and thus have
minimal gastric side effects.minimal gastric side effects.

23. DMARDsDMARDs:: ((Disease Modifying Anti Rheumatic Drugs)Disease Modifying Anti Rheumatic Drugs)
– DMARDs represent the most important measure inDMARDs represent the most important measure in
the successful treatment of RA. DMARDs can retardthe successful treatment of RA. DMARDs can retard
or prevent disease progression and, thus, jointor prevent disease progression and, thus, joint
destruction and subsequent loss of function.destruction and subsequent loss of function.
– Successful DMARD therapy may eliminate the needSuccessful DMARD therapy may eliminate the need
for other anti-inflammatory or analgesic medications.for other anti-inflammatory or analgesic medications.
– Until the full action of DMARDs takes effect, anti-Until the full action of DMARDs takes effect, anti-
inflammatory or analgesic medications may beinflammatory or analgesic medications may be
required as bridging therapy to reduce pain andrequired as bridging therapy to reduce pain and
swelling.swelling.

24. DMARDs – 2 typesDMARDs – 2 types
1) Non-Biological: Methotrexate, Chloroquine,1) Non-Biological: Methotrexate, Chloroquine,
Hydroxychloroquine, Sulphasalazine, D-Hydroxychloroquine, Sulphasalazine, D-
Pencillamine, Gold salts, Azathioprine,Pencillamine, Gold salts, Azathioprine,
LeflunomideLeflunomide
2) Biological: Block pro-inflammatory cytokines2) Biological: Block pro-inflammatory cytokines
(a) TNF-alpha blockers – etanercept, Infliximab(a) TNF-alpha blockers – etanercept, Infliximab
(b) IL-1 blockers - Anakinra(b) IL-1 blockers - Anakinra

25.  Surgical treatmentSurgical treatment::
Involvent of C1 and C2 vertebrae mayInvolvent of C1 and C2 vertebrae may
need surgical intervention.need surgical intervention.
Synovectomy, Tendon repair and JointSynovectomy, Tendon repair and Joint
replacements may be needed.replacements may be needed.

26. Rheumatoid ArthritisRheumatoid Arthritis
 PrognosisPrognosis
– Patients can follow two divergent courses:Patients can follow two divergent courses:
(1) 50-75% experience remission in 2 years (these(1) 50-75% experience remission in 2 years (these
patients have good functional status even duringpatients have good functional status even during
disease activity).disease activity).
(2) Patients who have severe disease have a worse(2) Patients who have severe disease have a worse
prognosis, and on an average die 10-15 years earlierprognosis, and on an average die 10-15 years earlier
than people without RA.than people without RA.

27.  Juvenile chronic arthritisJuvenile chronic arthritis is similar tois similar to
rheumatoid arthritis but is seen in children.rheumatoid arthritis but is seen in children.
Four forms are recognized:Four forms are recognized:
– polyarticular form resembles adult RApolyarticular form resembles adult RA
– oligoarticular form affects young girls duringoligoarticular form affects young girls during
peak ages of 2-4peak ages of 2-4
– systemic onset disease or Still’s disease issystemic onset disease or Still’s disease is
characterized by fever and rashcharacterized by fever and rash
– a juvenile form of ankylosing spondilitisa juvenile form of ankylosing spondilitis