RHEUMATOID ARTHRITIS (RA)

Definition: Chronic destructive of joint inflammation

with pain and swelling,mainly characterized by
inflammation of the lining (synovium) of the joints .
 In a considerable proportion of patients, the arthritis
is progressive, resulting in joint destruction and
ultimately incapacitation and increased mortality.

Relatively common,
Prevalence: 0.3-1.5 %
Male:female ratio. 1:3.
Typical case: woman aged 30-40 years with polyarthritis
and early joint deformities.

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Etiology :
1-Gentic factor : May be involved because it is usually
associated with HLA-DR4
2-Autoimmunity: RA is considered to be an autoimmune
disease for the following reasons:
There is defect in cell mediated immunity .
3-Female gender: is a risk factor and this susceptibility is
increased post-partum and by breast feeding
4-Cigarette smoking : is also a risk factor

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Pathogenesis :.
Is a disease of the synovium.
Inflammation :The synovium shows signs of chronic
inflammation .
Proliferation : The synovial membrane then proliferates
and grows out over the surface of the cartilage, which
causes erosion and destruction of the cartilage .

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CytokineCytokinek
interactions
interakciói

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 Rheumatoid Synovium
Normal Synoviumca Rheumatoid Synovium

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Symptoms of Rheumatoid Arthritis:
• Symptoms first begin in the small joints of the fingers,
wrists and feet, with warm, swollen and tender joints
that are painful and difficult to move.
• Joints of both sides of the body (symmetrical) are
typically affected.
• People with RA often experience fatigue, loss of
appetite and low-grade fever.
• There is often stiffness in the morning that lasts for
several hours or more.
• Nodules may form under the skin, often over the bony
areas exposed to pressure (such as the elbows).
• Over time, damage to the cartilage and bone of the
joints may lead to joint deformities. 8
 Classification criteria of RA
1. Morning stiffness – for at least 1 hr and present for at
least 6 weeks
2. Swelling of 3 or more joints for at least 6 weeks
3. Swelling of wrist, MCP or PIP joints for at least 6
wks
4. Symmetric joint swelling
5. Typical radiologic changes in hands (erosions or
unequivocal bony decalcification)
6. Rheumatoid nodules
7. Serum rheumatoid factor (RF) positivity

Diagnosis is made by the presence of 4 or more criteria

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Differential diagnosis of polyarthritis
RA should be differentiated from
- Other autoimmune diseases (SLE, Sjögren’s syndrome,
giant cell vasculitis, polymyalgia rheumatica etc) 
- Viral diseases (parvovirus, rubella, hepatitis B & C )
- Bacterial infections (TB, rheumatic fever, septic
endocarditis, mycoplasma arthritis)
- Seronegative spondylarthritides (erosive psoriatic
arthitis, reactive arthritis, enteropathic arthritis)
- Paraneoplastic arthritis
- Other diseases (e.g. hyperthrophic osteoarthropathy,
erythema nodosum, acromegaly, diabetes mellitus)
- Other rheumatic diseases (chronic gout, inflamed
erosive osteoarthritis) 10
Signs of early RA (=undifferentiated arthritis)
In the early stage (within the first 3-6 months)
classification criteria cannot be used.

The patient should be referred to a rheumatologist, if

The patient has 3 or more swollen joints

         The metacarpophalangeal (MCP) and/or
metatarsophalangeal (MTP) joints are involved; The
squeeze test is positive
         Morning stiffness is 30 min or more.

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 How to diagnose a case of RA
HISTORY:
Insidious onset
Slow development of sign & symptoms
Stiffness
Polyarticular
Most common: PIP & MCP of hands
Morning stiffness > 1hr
Fatigue, malaise, depression

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 Joint involvement in RA
The most specific sign of RA is arthritis.
It is progressive and deforming in the majority (2/3)
of cases (= erosive polyarthritis)

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RA early stage
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Early assymmetric RA 15
PIP joint involvement in RA
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RA: swan neck deformity
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RA: ulnar deviation 18
Ulnar deviation in RA with severe atrophy of interosseal
muscles
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RA: Boutonnière deformity
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RA: arthritis mutilans
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Involvement of joints of feet in RA
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Severe destruction of ankles in RA
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Bursitis in the shoulder 24
Bursitis and rheumatoid nodule
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Rheumatoid nodules 26
RA – end stage
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Laboratory Tests
Initial work-up
CBC, Metabolic panel, Urinalysis,

Rheumatoid factor, Anti-nuclear antibody.

ESR: elevated

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Radiology:
X-Ray
MRI
Bone Scan

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Periarticular osteoporosis (decalcification)
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Erosions and sclerosis (in late stage)
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Erosion in RA
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Early erosions (MRI)
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Scinti-graphy of the hands

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 Extraarticular manifestations of RA
• Rheumatoid nodules – subcutaneous
- in internal organs (lung, aortic valve)
• Pleuritis/pericarditis
• Fibrotizing alveolitis
• Vasculitis
• Amyloidosis

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Systemic manifestations of RA: pulmonary fibrosis

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Rheumatoid nodules in the lungs
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Episcleritis in RA
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Scleritis in RA
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Vasculitis in RA

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Vasculitis in RA
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