RA KIBRIS 2024.pdf

Rheumatoid Arthritis Prof. Mehmet Tuncay Duruöz Marmara University Medical School Head of PMR Department & Rheumatology Division Istanbul Introduction  Systemic, autoimmun rheumatic disease seen in clinical practice affecting approx 1% of population.  Chronic multisystem disease of unknown cause....

Rheumatoid Arthritis Prof. Mehmet Tuncay Duruöz Marmara University Medical School Head of PMR Department & Rheumatology Division Istanbul Introduction  Systemic, autoimmun rheumatic disease seen in clinical practice affecting approx 1% of population.  Chronic multisystem disease of unknown cause.  Characterized by persistent inflammatory synovitis leading to cartilage damage, bone erosions, joint deformity and disability. Onset  Although Rheumatoid arthritis may present at any age, patients most commonly are first affected in the third to sixth decades.  Female: male 3:1  Initial pattern of joint involvement could be:1) Polyarticular : most common 2) Oligoarticular 3) Monoarticular  Morning joint stiffness > 1 hour and easing with physical activity is characteristic.  Small joints of hand and feet are typically involved. Clinical Manifestations  Articular  Extra-articular Articular manifestation  Pain in affected joint aggravated by movemnt is the most common symptom.  Morning stiffness ≥1 hr  Joints involved -→ Relative incidence of joint involvement in RA  MCP and PIP joints of hands & MTP of feet  Knees, ankles & wrists-  Shoulders Elbows TM, Acromio - clavicular & SC joints- 90% 80% 60% 50% 30% Joints involved in RA  Don’t forget the cervical spine!! Instability at cervical spine can lead to impingement of the spinal cord.  Thoracolumbar, sacroiliac, and distal interphalangeal joints (DIP)of the hand are NOT involved. PIP Swelling Ulnar Deviation, MCP Swelling, Left Wrist Swelling Extra-articular manifestations  Present in 30-40%  May occur prior to arthritis  Patients that are more likely to get are:  High titres of RF/ anti-CCP  HLA DR4+  Male  Early onset disability  History of smoking Extraarticular Involvement  Constitutional symptoms ( most common)  Rheumatoid nodules(30%)  Hematological normocytic normochromic anemia  leucocytosis /leucopenia  thrombocytosis  Felty’s syndrome Chronic nodular Rheumatoid Arthritis  Spleenomegaly  Neutropenia  Respiratory- pleural effusion, pneumonitis , pleuro    pulmonary nodules, ILD CVS-asymptomatic pericarditis , pericardial effusion, cardiomyopathy Rheumatoid vasculitis- mononeuritis multiplex, cutaneous ulceration, digital gangrene, visceral infarction CNS- peripheral neuropathy, cord-compression from atlantoaxial/midcervical spine subluxation, entrapment neuropathies EYE- kerato cunjunctivitis sicca, episcleritis, scleritis Rheumatoid nodule Laboratory investigations in RA  CBC- TLC, DLC, Hb, ESR & GBP  Acute phase reactants  Rheumatoid Factor (RF)  Anti- CCP antibodies (ACPA) Rheumatoid Factor (RF)  Antibodies that recognize Fc portion of IgG  Can be IgM , IgG , IgA  85% of patients with RA over the first 2 years become RF+ A negative RF may be repeated 4-6 monthly for the first two year of disease, since some patients may take 18-24 months to become seropositive. PROGNISTIC VALUE- Patients with high titres of RF and ACPA, in general, tend to have POOR PROGNOSIS, MORE EXTRA ARTICULAR MANIFESTATION. Causes of positive test for RF  Rheumatoid arthritis  Sjogrens syndrome  Vasculitis such as polyarteritis nodosa  Sarcoidosis  Systemic lupus erythematosus  Cryoglobulinemia  Chronic liver disease  Infections- tuberculosis , bacterial endocarditis, infectious mononucleosis, leprosy, syphilis, leishmaniasis.  Malignancies  Old age(5% women aged above 60) Anti-CCP (ACPA)  IgG against synovial membrane peptides damaged via inflammation  Sensitivity (65%) & Specificity (95%)  Both diagnostic & prognostic value  Predictive of Erosive Disease  Disease severity  Radiologic progression  Poor functional outcomes Other Lab Abnormalities  Elevated APRs( ESR, CRP )  Thrombocytosis  Leukocytosis  ANA  30-40%  Inflammatory synovial fluid  Hypoalbuminemia Radiographic Features  Peri-articular osteopenia  Uniform symmetric joint space narrowing  Marginal subchondral erosions  Joint Subluxations  Joint destruction  Collapse  Ultrasound detects early soft tissue lesions.  MRI has greatest sensitivity to detect synovitis and marrow changes. ACR Criteria (1987)  1.Morning Stiffness ≥1 hour  2.Arthritis of ≥ 3 joints observed by physician Rt/Lt-PIP, MCP,wrist, elbow, simulteneously- knee, ankle, MTP  3.Arthritis of hand joints-PIP,MCP,wrist  4. Symmetric arthritis  5. Rheumatoid nodules  6. Positive Rheumatoid Factor  7. Radiographic Erosions or periarticular osteopenia in hand or wrist joints  Criteria 1-4 must be present for ≥6 wks  Must have ≥4 criteria to meet diagnosis of RA 2010 ACR/EULAR Classification Criteria  a score of ≥6/10 is needed for classification of a patient as having definite RA  A. Joint involvement SCORE  1 large joint  2−10 large joints 1−3 small joints (with or without involvement of large joints)  4−10 small joints (with or without involvement of large joints)  >10 joints (at least 1 small joint)†† 0 1 2 3 5  B. Serology (at least 1 test result is needed for classification)  Negative RF and negative ACPA  Low-positive RF or low-positive ACPA  High-positive RF or high-positive ACP 0 2 3  C. Acute-phase reactants (at least 1 test result is needed for classification)  Normal CRP and normal ESR  Abnormal CRP or normal ESR 0 1  D. Duration of symptoms 