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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
  • Prognosis
    • certain patients with early rheumatoid arthritis may achieve remission
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
  • Diagnostic criteria
    • diagnosis is based on clinical presentation and laboratory studies
Differential
  • Systemic lupus erythematous
  • Psoriatic arthritis
  • Scleroderma
  • Polymyalgia rheumatica
  • Gout
  • Osteoarthritis
  • Parvovirus B19
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
        • 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 subluxation
  • Popliteal cyst
  • Greater risk of osteoporosis and osteopenia secondary to steroid use, inactivity, and disease process
  • Nephrotic syndrome
    • result of amyloid deposition  
 
 

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