Rheumatoid arthritis (Causes, Symptoms, Diagnosis, Treatment)

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a systemic autoimmune disorder that is characterized by chronic, destructive, inflammatory arthritis with symmetric joint involvement that results in hypertrophy and pannus formation. This disease typically attacks the synovial joints, ultimately leading to erosion of adjacent bone, tendons, and cartilage.

What are the possible causes of RA?

The causes of rheumatoid arthritis are still not completely known. Some experts say that rheumatoid arthritis is genetic. It is strongly associated with HLA-DR4.

What is HLD – DR4 Gene?

This gene is one of the genetic markers of Rheumatoid Arthritis. It is also known to show involvement in Lyme Disease.

Click here for further information about Lyme Disease.

People at the late stages of the disease with severe symptoms, not responding to antibiotics are found the have the HLA-DR4 gene. It has been described by the researchers that when microorganisms move to the joint, the body’t immune response against the microorganisms cross react with the body’s own tissue resulting in initiation of an autoimmune reaction. This auto immune reaction in turn causes pain and inflammation.

Who is at the risk of developing rheumatoid arthritis?

Females, 35-50 years old, are more likely to develop rheumatoid arthritis as compared to men. The individuals with positive family history of rheumatoid arthritis are also at high risk.

Presentation of rheumatoid arthritis

Sign & Symptoms

Rheumatoid arthritis primarily affects the joints. The joints become tender, warm, swollen and stiff which limits their movement. As the time passes, RA attacks multiple joints. This condition is known as polyarthritis. Small joints, such as joints of hands and feet, are affected more often than larger joints. . Joints like knee and shoulder can also be involved but it is very rare.

The typical case of rheumatoid arthritis presents with insidious onset of morning stiffness for more than one hour along with warm and painful swelling of multiple symmetric joints such as wrist, metacarpal joints, shoulders, elbows, hips, knees, and ankles for more than six weeks.

Patients may also complain of:

• Fever
• Fatigue
• Anorexia
• Malaise
• Weight loss

In late cases, ulnar deviation of the fingers occurs with hypertrophy of metacarpal joints.

Patients suffering from rheumatoid arthritis may also present with:

• Ligament and tendon deformations such as swan-neck and buotonniere deformities
• Vasculitis
• Atlantoaxial subluxation
• Keratoconjuctivitis sicca

Note only the joints; rheumatoid arthritis may also affect other organs/systems such as

• Skin
• Lungs
• Kidneys
• Heart
• Blood vessels

Local osteoporosis may also occur due to rheumatoid arthritis

How is RA Diagnosed?

Radiographs: X-rays of hands and feet are usually performed in the people suffering from polyarthritis. Early stages of rheumatoid arthritis show normal x-ray. However, soft tissue swelling and juxta-articular demineralization may be seen. In the late stages, symmetrical joint space narrowing and erosions are usually seen on x-rays.

Complete blood count (CBC): CBC shows

• Raised WBCs (may rise up to 50,000 cells/µL)
• Raised ESR
• Low hemoglobin (anemia of chronic disease)
• Raised rheumatoid factor (RF)
• Presence of anti-CCP antibodies “ specific but not diagnostic

Synovial fluid aspirate: It shows turbid fluid and decreased viscosity.

Am I really suffering from RA? Differential diagnosis “ rheumatoid arthritis

There are other diseases that may mimic rheumatoid arthritis. Don't make the final diagnosis on your own without physician's opinion. Here are the diseases that must be ruled out before making the final diagnosis.

• Gout & pseudogout
• Osteoarthritis
• Systemic lupus erythematosus
• Psoriatic arthritis
• Reactive arthritis
• Ankylosing spondylitis

How is rheumatoid arthritis treated?

There is no treatment that can cure this disease. However, some drugs improve the symptoms and decrease the disease progression. The purpose of the treatment is to prevent bone deformity and relief the symptoms such as pain and swelling.

Medications

Disease-Modifying Anti-Rheumatic Drugs (DMARDs):

DMARDs are the first line drugs in case of RA. Almost all the patients suffering from rheumatoid arthritis are treated with at least one DMARD.

DMARDs include:

• Methotrexate
• Hydroxychloroquine
• Sulfasalazine

Methotrexate is the best initial DMARD to start with.

Second-line agents

Second-line agents are the drugs that are used if first line therapy drugs are contraindicated. Second-line drugs include:

• Tumor Necrosing Factor (TNF) inhibitors
• Rituximab (anti-CD20)
• Leflunomide

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):

NSAIDs are usually prescribed to the patients with RA to relief symptoms, such as pain and swelling, which affect the patients' daily life.

Key facts about rheumatoid arthritis that you must know

• Keratoconjunctivitis sicca secondary to Sjogren's syndrome is a common ocular manifestation of rheumatoid arthritis
• Felty's syndrome is characterized by:
  • Rheumatoid arthritis
  • Splenomegaly
  • Neutropenia
• The distal inter phalyngeal joint is spared in rheumatoid arthritis but is involved in osteo-arthritis
• Hydroxychloroquine causes retinal toxicity

Reference:

https://www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html

https://www.niams.nih.gov/Health_Info/Rheumatic_Disease/

https://www.nlm.nih.gov/medlineplus/ency/article/000431.htm

https://www.arthritis.org/types-what-is-rheumatoid-arthritis.php