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Dr. Maria Michailidou


                                                                       RHEUMATOID ARTHRITIS

General Considerations

Rheumatoid arthritis is a chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints. It has a prevalence of 1% and is more common in women than men (female:male ratio of 3:1). Rheumatoid arthritis can begin at any age, but the peak onset is in the fourth or fifth decade for women and the sixth to eighth decades for men. The cause is not known. Susceptibility to rheumatoid arthritis is genetically determined with multiple genes contributing. Inheritance of class II HLA molecules with a distinctive five-amino-acid sequence known as the "shared epitope" is the best characterized genetic risk factor. Untreated, rheumatoid arthritis causes joint destruction with consequent disability and shortens life expectancy. Early, aggressive treatment is now the standard of care.

The pathologic findings in the joint include chronic synovitis with formation of a pannus, which erodes cartilage, bone, ligaments, and tendons. In the acute phase, effusion and other manifestations of inflammation are common. In the late stage, organization may result in fibrous ankylosis; true bony ankylosis is rare. In both acute and chronic phases, inflammation of soft tissues around the joints may be prominent and is a significant factor in joint damage.

Clinical Findings in rheumatoid arthritis

Symptoms and Signs

Joint symptoms

The clinical manifestations of rheumatoid disease are highly variable, but joint symptoms usually predominate. Although acute presentations may occur, the onset of articular signs of inflammation is usually insidious, with prodromal symptoms of vague periarticular pain or stiffness. Symmetric swelling of multiple joints with tenderness and pain is characteristic. Monarticular disease is occasionally seen initially. Stiffness persisting for more than 30 minutes (and usually many hours) is prominent in the morning; the duration of morning stiffness is a useful indicator of disease activity. Stiffness may recur after daytime inactivity and be much more severe after strenuous activity. Although any diarthrodial joint may be affected, PIP joints of the fingers, MCP joints, wrists, knees, ankles, and MTP joints are most often involved. Synovial cysts and rupture of tendons may occur. Entrapment syndromes are not unusual—particularly of the median nerve at the carpal tunnel of the wrist. Rheumatoid arthritis can affect the neck but spares the other components of the spine and does not involve the sacroiliac joints.

Rheumatoid nodules

Twenty percent of patients have subcutaneous rheumatoid nodules, most commonly situated over bony prominences but also observed in the bursae and tendon sheaths. Nodules are occasionally seen in the lungs, the sclerae, and other tissues. Nodules correlate with the presence of rheumatoid factor in serum ("seropositivity"), as do most other extra-articular manifestations.

Ocular symptoms

Dryness of the eyes, mouth, and other mucous membranes is found especially in advanced disease (see Sjögren's syndrome). Other ocular manifestations include episcleritis, scleritis, and scleromalacia due to scleral nodules


Photos of rheumatoid arthritis