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Rheumatoid arthritis
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Rheumatoid arthritis (RA)
RA is the most common inflammatory arthritis characterized by symmetrical and deforming of the small and large joint polyarthritis associated with systemic disturbance and extra-articular manifestations with intermittent exacerbations and remissions The prevalence increases with age , more in female 3:1 male , the RA is uncommon in men under the age of 45, where there is a 6: 1 female excess
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Aetiology No single factor has been identified to date
Genetic susceptibility is important HLA –DR 4 occurring in % of Caucasian patients compared to 20 – 25 % of normal population Female gender is a risk factor No infectious agent has been isolated Presence of immune complexes at site of articular and extra articular lesion
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Pathology Swelling and congestion of the synovial membrane due to infiltration of lymphocyte , plasma cell and macrophage with effusion of synovial fluid in the joint place Hypertrophy of the synovial membrane Inflammatory granulation tissue (pannus ) spread over and under the articular cartilage which is progressively eroded and destroyed
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Later , fibrosis and bony ankylosis may occur
Muscle atrophy with focal infiltration with lymphocyte Subcutaneous nodules consist of central area of fibrinoid material surrounded by palisade of mononuclear cell , similar granulation lesion may occur in the pleura , lung, pericardium and sclera
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Clinical features Gradual onset of symmetrical arthralgia and synovitis of the small joints of the hands , feet and wrists . 10 % acute onset 5 % palindromic with recurrent symmetrical acute episodes of J. pain and swelling which last only for few hours or days Moring stiffness more than 1 hour Symmetrical swelling of the MCP and PIP J
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Deformities of R.A Specific hand abnormalities include Swan neck deformity , the boutonniere or button hole deformity and Z deformity of the thumb , triggering of fingers and dorsal sublaxations of the ulnar styloid In the fore foot dorsal sublaxation of the MTP J result in cock up deformity , callosities over the MTP head In the hind foot , calcaneovalgus ( eversion ) deformity reflecting damage to the ankle and subtalar J .
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Popliteal cyst ( Baker’s ) can occur in combination with knee synovitis and sometimes complicated by rupture which induced by knee flexion lead calf pain and swelling Extra – articular features : anorexia , weight loss and fatigue Generalized osteoporosis and muscle wasting These features occur mainly in sero positive erosive disease especially in men
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Cutaneous features : subcutaneous nodules occur in sero positive patients at site of pressure or friction such as extensor surface of the forearm , sacrum , Achilles' tendon and toes Systemic rheumatoid vasculitis in form of nail fold infarct , cutaneous ulceration with skin necrosis
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Extra-articular manifestations Occular features
Dry eye ( keratoconjunctivitis sicca ) Painless episcleritis ( intense redness , no visual disturbance ) Scleritis ( more serious and sight threatening ) the eyes are red and painful , pupil was irregular due to adhesion ( synechiae ) Corneal melting associated with systemic vasculitis may progress to perforation
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Cardiovascular features
Asymptomatic pericarditis in 30 % Pericardial effusion , constrictive pericarditis Heart block , cardiomyopathy , coronary artery occlusion or aortic regurgitation
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Pulmonary features Fibrosing alveolitis
Pleural effusion especially in the men with sero positive , usually small , unilateral and resolved spontineously Rh pulmonary nodule sub pleural and usually multiple , combination of Rh. Nodule and pneumoconiosis is known as Kaplan’s syndrome Bronchitis and Bronchiectasis
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Neurological features
Entrapment neuropathy (median nerve compression ) , ulnar nerve compression at the elbow , lateral popliteal nerve at the head of the fibula , tarsal tunnel syndrome Symmetrical peripheral neuropathy Mono neuritis multiplex Cervical cord compression result from sublaxation of the cervical spine at the atlanto – axial J or at sub axial level
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Haematological features
Microcytic iron deficiency anemia due to NSAID Normochromic normocitic anemia , thrombosis due to active disease Felty’s syndrome (spleanomegally , lymphadenopathy , neutropenia , weight loss , skin pegmintation , K C Sicca Long standing deforming sero positive RA Lymphadenopathy localized or generalized due to lymphoma in long standing disease Amyloidosis is a rare complication
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Investigations 1- Clinical criteria : Morning stiffness >1 hr
Arthritis of 3 or more Js. Arthritis of hand Js . Symmetrical arthritis Rh. Nodules Rh. Factor Radiological features Duration of 6 weeks or more ** Dx of RA is made of four or more criteria
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2) Elevated acute phase protein
3) Rh.F present in % ( 10 % of normal population ) 4 ) radiographs shows : periarticular osteopenia Marginal non – proliferative erosions
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Management Physical rest Passive exercise in acute RA
Hospital admission in severe condition ( patient needs intra articular injection , J. splinting , regular hydrotherapy and physiotherapy NSAIDS Prednisolone 7.5 mg /day DMARDS ( single or in combination , used early before radiological changes appears Methotrexate and Sulfasalazine are current first choice
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Surgery Synovectomy to relieve pain and prevent tendon rupture
Osteotomy Arthrodesis Arthroplasty
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Prognosis 5 years survival for the patient with severe disease is 50 %
40 % disabled within 3 years 80 % will be moderately to severely disabled within 20 years and 25 % require large J. replacement
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Poor prognosis factors
Higher baseline disability Female gender Involvement of the MTP +ve Rh F Disease duration of over 3 months
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MCP & PIP arthritis
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PIP arthritis
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MCP arthritis & wasting of extensor ms.
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Wrist & PIP arthritis
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Z-deformity & MCP arthritis
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Wrist , MCP & PIP arthritis
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Ulnar deviation & Z deformity
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Swan neck deformity
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MCP arthritis , ulnar deviation
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Wasting of extensor ms
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Piano – glass deformity
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Rheumatoid nodules - elbow
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Rheumatoid nodules –dorsum of hand
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Vasculitis
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vasculitis
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Osteopenia & dec J. space
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Soft tissue swelling
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Sclerosis and dec j. space
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Joint erosion
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Bilateral ulnar deviation of PIP J.
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Ulnar deviation of PIP J.
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