Snapshot A 35-year-old woman presents with joint stiffness and pain of the hands and wrists for the last two months. Her symptoms are most severe in the morning and improve in the afternoon. She reports an unintentional loss of 15 pounds over the course of 3 months as well as fatigue. On physical exam, there is swelling and tenderness at the metacarpophalangeal and proximal interphalangeal joints. Introduction Clinical definition a chronic autoimmune disorder that primarily affects the joints and results in an inflammatory synovitis Epidemiology Demographics sex more common in women age 30-50 years of age Risk factors smoking Etiology Environmental and genetic factors play a role Pathogenesis T- and B-cell response after a triggering event (e.g., infection in a genetically susceptible patient) eventually results in pannus formation and subsequent damage to the adjacent cartilage and bone Th1 cells release interferon-γ (IFN-γ) in order to activate macrophages and synovial cells Th17 cells secrete interleukin-17 (IL-17) in order to recruit monocytes and neutrophils synovial plasma cells produce antibodies against self-antigens such as citrullinated peptides Genetics HLA-DR4 Associated conditions Sjogren syndrome Felty syndrome seropositive rheumatoid arthritis with neutropenia many patients have splenomegaly Caplan syndrome seropositive rheumatoid arthritis with pneumoconiosis Presentation Symptoms fatigue and depression morning stiffness that lasts > 1 hour pain, stiffness, and/or swelling of the joint such as the metacarpophalangeal (MCP) joints proximal interphalangeal (PIP) joints metatarsophalangeal (MTP) joints Physical exam anemia of chronic disease weight loss decreased grip strength palmar erythema subcutaneous (rheumatoid) nodules splenomegaly in cases of Felty syndrome ulnar deviation of the fingers swan neck deformity bouttoniere deformities Imaging Radiography indications can be obtained during the initial workup to have a baseline to compare to when following disease progression can be performed of the neck to rule out odontoid ligament laxity modality hands, wrists, and feet findings diffuse osteopenia joint space narrowing in the carpal, metacarpal, phalangeal, and interphalangeal joints periarticular bony erosions ulnar deviation of the fingers Studies Labs rheumatoid factor (RF) antibody testing RF is an IgM antibody that targets the Fc portion of IgG anti-CCP antibody testing more specific for rheumatoid arthritis erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels typically elevated Differential Systemic lupus erythematous Psoriatic arthritis Scleroderma Polymyalgia rheumatica Gout Osteoarthritis Parvovirus B19 mild symmetric arthralgias and a viral syndrome that is self-limited in adults slapped cheek fever in children DIAGNOSIS Diagnostic criteria diagnosis is based on clinical presentation and laboratory studies Treatment Conservative education, exercise, physical therapy, vaccinations, smoking cessation, and counseling indication a component of treatment for patients with rheumatoid arthritis Medical disease-modifying antirheumatic drugs (DMARDs) indication used to prevent, stop, or retard disease-associated damage medications methotrexate typically the initial DMARD used side-effects include GI symptoms, oral ulcers, macrocytic anemia, and hepatotoxicity tumore necrosis factor (TNF) inhibitor such as etanercept adalimumab leflunomide sulfasalazine hydroxychloroquine nonsteroidal antiinflammatory drugs (NSAIDs) and/or glucocorticoids indication initially given for symptomatic control while waiting for DMARD response Operative joint replacement surgery indication in patients with severe joint damage or failure to respond to conservative and medical therapy Complications Hand deformities Atlantoaxial (cervical) subluxation paralysis hyporeflexia occurs when manipulating the neck Popliteal cyst Fluid collection behind the knee Can rupture, leading to posterior knee pain which radiates down the calf Greater risk of osteoporosis and osteopenia secondary to steroid use, inactivity, and disease process bisphosphantes is an effective prophylactic therapy in these patients Nephrotic syndrome result of amyloid deposition Prognosis Certain patients with early rheumatoid arthritis may achieve remission