Rheumatoid

arthritis

Ng Li Hwee
Tey Shelina
Shevern Yeoh
Chuah Wei Hong

Case study
A 32- year old nurse presents with a complaint of
intermittent episodes of pain, stiffness and swelling in
both hands and wrists for
approximately 1 year.

General Characteristics
RA is a chronic inflammatory autoimmune disease
involving the synovium of joints. The inflamed
synovium can cause damage to cartilage and bone.
It is a systemic disease that has many extra-articular
manifestations
Usual age of onset : 20-40 years
More common in women than men (3:1)

Clinical features
Typical presentations : pain, joint swelling and
stiffness affecting the small joints of the hands, feet
and wrists.
By convention, the symptoms need to persist for
more than 6 weeks for the diagnosis of RA

 Typical features are symmetrical swelling of the MCP

joints and proximal IP joints
They are tender on pressure and have stress pain on
passive movement or effusion/soft tissue swelling
Hand deformities :
1. swan neck deformity
2. boutonniere deformity
3. Z deformity of the thumb
4. dorsal subluxation of ulna at the distal radio-ulnar joint
5. triggering fingers.

 Foot deformities :
- dorsal subluxation of the MTP joints leading to cock
up toe deformity pain on weight-bearing on the
exposed MTP heads secondary bursae and callosities

 Hind foot : calcaneovalgus (eversion), flat foot

 Popliteal / Bakers cyst usually in combination with knee

synovitis

Case Study
More recently, she noticed similar symptoms in her
knees and ankles.
Joint pain and stiffness usually lasts for several hours
before improving.
She also reports malaise and easy fatigability for the
past few months, but she denies having fever, chills, skin
rashes and weight loss.

Osteoarthritis!
???

Considerations
The patient's history , including the symmetric peripheral
polyarthritis and duration of symptoms, is suggestive of
rheumatoid arthritis.
RA is a systemic autoimmune disorder of unknown etiology.
It's major distinctive feature is a chroni,c symmetric and
erosive synovitis of peripheral joints, which, if untreated,
leads to deformity and destruction of joints due to erosion of
cartilage and bone.
The diagnosis of RA is a clinical one, based on the presence
of combination of the clinical findings, laboratory
abnormalities and radiographic erosions.

Physical Examination
Tey Shelina
1001439084

INVESTIGATIONS
SHEVERN YEOH
1001439085

LABORATORY
Anticyclic citrullinated peptide antibodies (ACPA/antiCCP) (~98%) highly specific
Rheumatoid Factor (+ve in 70%)
Sjogren syndrome
Feltys syndrome
RA
High titre- severe disease, erosion, extra-articular disease

Infection (SBE/IE, hepatitis)

Mixed connective tissue diseases
SLE
Systemic sclerosis
Healthy population

FBC
Hb
Platelets
ESR (may be normal)
CRP (may be normal)

SYNOVIAL FLUID
ANALYSIS
WBC (500-50,000 WBC/)
norm = <2000 (osteoarthritis)

Neutrophilia
RF
Anti-CCP antibodies
Immune complexes

Polarized light microscopy (for crystals)

Culture
Gram stain
Blood, pus, crystals

Useful to confirm inflammatory arthritis

Able to exclude osteoarthritis, gout, pseudogout

JOINT IMAGING
For diagnosis & tracking progression
of the disease
Plain X-Ray
initially: juxtaarticular osteopenia (diff to
appreciate)
wrist, hands
Soft tissue swelling
(MCP, PIP)
Feet (MTP)
Symmetric joint space loss
Subchondral erosions
In feet:
Lateral aspect of 5th MTP- 1st target

Advanced RA
Sublaxation and collapse

MRI, ULTRASOUND
Greatest
sensitivity to
detect synovitis,
joint effusions,
bone and bone
marrow changes
Bone marrow
edema (early
signs of
inflammatory
joint disease)
Bone errosions

assess
disease
activity, the
response to
treatment
and the need
for biological
therapy
higher the
value, the
more active
the disease

Laboratory studies show mild

anemia with hemoglobin
11.2g/dL (11.5-16.0), hematocrit
32.5% (34.9-44.5%), MCV 85.7fL
(76-96), WBC count 7.9/mm (411) with a normal differential,
and platelet count 300,000/mm
(150,000-400,000). Urinalysis is
clear with no protein and no
RBC. The ESR is 75 mm/h (0-29).
Kidney and liver function tests

Management

Chuah Wei Hong

Aim: Remission or lowest possible

disease activity
To intervene as early as possible (Rheumatology
referral and Initiation of DMARDS)
Delays in starting appropriate therapy can cause long term
differences in outcome.

To reduce and prevent synovitis

Damage can occur early in disease

Management

NonPharmacolog
ical

Pharmacolog
ical

Pharmacological
NSAIDS, DMARDS,
Immunosuppressant,
Corticosteroids.

Non-Pharmacological
Exercise, Diet, Massage,
Counselling, Stress Reduction,
Physical Therapy, Surgery.

Disease Modifying Anti-Rheumatic

Drugs (DMARDS)
First line for treating RA
Early DMARDS is associated with better long term
prognosis.
Methotrexate: the gold standard and is first-line unless
contraindicated
Delayed onset of action (may take 8-12 weeks)
Adverse effects: Potential hepatotoxicity, low white
blood cell count, teratogenic
If inadequate response (3-6 months), combine or switch
Other DMARDS include: hydroxychloroquine,
sulfasalazine, leflunomide

Biological Therapies
Agents include

Anti-TNF (infliximab, etanercept, adalimumab)

Inhibitor of T-cell Activation (abatacept)
Anti B-cell (rituximab)
Anti IL-6 (tocilizumab) etc.

Indicated if inadequate response to DMARDs (after 3 months)

MOA: Act on specific cytokines and other cell-surface
molecules regulating the immune response.
Well tolerated but increase risk of serious infection
Greater treatment cost
Initiated only if:
DSA 28>5.1
Adequate trial of at least 2 DMARDs has failed

NSAIDS
For symptoms relief
No effect on disease progression
Individualize according to efficacy and
tolerability
CI: Peptic Ulcer Disease, Ischemic Heart Disease

Corticosteroids
Local
Intra Articular injections to control symptoms
in a specific joint
Systemic (prednisone)
low dose (5-10 mg/d) useful for short-term to
improve symptoms if NSAIDs ineffective, to
bridge gap until DMARD takes effect
for severe RA, low dose prednisone can be
added to DMARDs
CI: active infection, TB, HTN.

Management of early RA

Surgery
Early Stage
Synovectomy

Later stage:
Osteotomy (bone cutting)
Arthrodesis
Arthroplasty

Thank you!