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Pathology

A multi-systemic autoimmune disorder affecting synovial joint membranes

Aetiology

HLA-DR4 found in 60% of RA patients
T cells activate macrophages leading to production of pro-inflammatory cytokines (TNF-alpha and IL-1)
B cells secret antibodies – Rheumatoid Facto  and anti-CCP 

Signs

Persistent symmetrical polyarthritis, Rheumatoid nodules, lymphadenopathy, pericarditis, pericardial effusion, vasculitis, pulmonary fibrosis
Swan Neck Deformity: PIP Hyperextension, DIP flexion due volar plate damage 
Boutonniere Deformity: PIP Flexion, DIP hyperextension
Z-Thumb Deformity: PIP Hyperextension with flexion and MCP subluxation 
Ulna Deviation: Deviation at the fingers

Symptoms

Joints: Inflammation with swelling, tenderness, warmth, decreased range of 
 motion and stiffness worst in morning and improved with movement
Extra-articular: Malaise, fatigue

Investigations

Bloods: FBC, Raised ESR and CRP, Rheumatoid Factor and anti-CCP 
Imaging: X-rays of joints involved, MRI or Ultrasound scan for small joints and periarticular soft tissues to assess for erosion
Joint Aspiration: Raised White Cell Count and Protein 

Treatment

Conservative: Exercise, diet, counselling, physiotherapy.
Medical: NSAIDs, Steroids, DMARDs such as Sulfasalazine, Methotrexate or 
Azathioprine and failure of 2 DMARDs leads to Biological Therapy using
TNF inhibitors e.g. Adalimumab or Immunomodulators e.g. Rituximab. 
Surgery: Synovectomy, reconstruction, arthroplasty and arthrodesis

Prognosis

Systemic involvement is poor prognostic factor
Cardiovascular: Endocarditis, Myocarditis, Pericarditis
Eyes: Episcleritis, Scleritis, Keratoconjunctivitis
Neurology: Peripheral Neuropathy
Respiratory: Nodules, Pleural Effusion, Fibrosing Alveolitis
Caplan’s Syndrome: Rheumatoid Arthritis In Coal Miners With Pneumoconiosis
Felty’s Syndrome: Positive Rheumatoid Factor, Splenomegaly, Neutropenia
Still’s Disease: Juvenile Arthritis, Fever, Rash.

Key Facts

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Key Images

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Key References

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