Rheumatoid Arthritis Presentation PDF
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Marmara University Medical School
Prof. Mehmet Tuncay Duruöz
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This presentation details Rheumatoid Arthritis, covering its introduction, onset, clinical manifestations, extra-articular manifestations, laboratory investigations, causes, diagnostic criteria, and treatment modalities. Focuses on disease modifying anti-rheumatic agents and biologicals, presented by Prof. Mehmet Tuncay Duruöz from Marmara University.
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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