Rheumatoid Arthritis

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Rheumatoid Arthritis:

Rheumatoid Arthritis Blaine Clark Alison D ’ Alessandro Allison Haynes


Facts 1,2 Progressive, systemic, inflammatory connective tissue disease affecting primarily the synovial joints Over time, bone erosion, destruction of cartilage, and complete loss of joint integrity Most common inflammatory arthritis Autoimmune disease Women affected 3x greater than men Peak age 35-40 Affects 3% of the population Commonly bilateral affecting wrists , fingers, knees, feet, and ankles


Symptoms 1,2 Progresses slowly with symptoms of fatigue, loss of appetite, low fever, swollen glands, weakness, and joint pain Morning stiffness is common Joints can become warm, tender, and stiff if sedentary in as little as an hour The fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck may be affected The joints are often swollen and feel warm and boggy (or spongy) to the touch. Over time, joints lose their range of motion and may become deformed. Other symptoms include : chest pain when taking a breath, nodules under the skin, numbness, tingling, burning in the hands and feet Joint destruction may occur within 1 - 2 years after the disease appears.


Signs 1 A blood test called anti-CCP antibody test may distinguish it from other arthritides Hand joint involvement C -reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Joint ultrasound or MRI Joint radiographs Rheumatoid factor test Arthritis of 3 or more joint areas

Risk Factors1:

Risk Factors 1 Female sex A positive family history Older age Silicate exposure Smoking Consumption of more than three cups of coffee daily—particularly decaffeinated coffee High vitamin D intake, tea consumption, and oral contraceptive use are associated with decreased risk

Criteria for the Classification of Rheumatoid Arthritisa Patient must have at least 4 of the 7 criteria. And the criteria 1-4 must be present for at least 6 weeks. :

Criteria for the Classification of Rheumatoid Arthritis a Patient must have at least 4 of the 7 criteria. And the criteria 1-4 must be present for at least 6 weeks. Criteria Definition 1. Morning Stiffness Morning stiffness in the around the joints, lasting at least 1 hour before maximal improvement 2. Arthritis of three or more joint areas At least three joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician. The 14 possible areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints. 3. Arthritis of hand joints At least one area swollen (as defined above0 in a wrist, MCP, or PIP joint. 4. Symmetric arthritis Simultaneous involvement of the same joint areas (as defined in 2) on both sides of the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry) 5. Rheumatoid nodules Subcutaneous nodules, over boney prominences, or extensor surfaces, or in juxtaarticular regions, observed by a physician 6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects 7. Radiographic changes Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify)


Diagnosis 1 Clinical evaluation: It is important to find out the degree of pain, duration of stiffness and fatigue, and functional limitations.


Radiograph 3 May not show any abnormalities in the earliest stages. With progress of the disease periarticular osteopenia can be detected through the presence of thinning bone. As the disease continues to progress and inflammation continues, radiographs can detect small erosive cysts ( subchondral erosions). These will most likely be detected in the MCP and PIP of the hand and MTP and PIP of the feet. With further progression of the disease destroyed cartilage and underlying bone can be seen.

Classification of Progression of Rheumatoid Arthritisa:

Classification of Progression of Rheumatoid Arthritis a Stage I, Early Stage II, Moderate Stage III, Severe Stage IV, Terminal *No destructive changes on roentgenographic examination Radiographic evidence of osteoporosis may be present *Radiographic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present *No joint deformities, although limitation of joint mobility may be present Adjacent muscle atrophy Extraatricular soft tissue lesions, such as nodules and tenosynovitis may be present *Radiographic evidence of cartilage and bone destruction, in addition to osteoporosis *Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis Extensive muscle atrophy Extra-articular soft tissue lesions, such as nodules and tenosynovitis may be present *Fibrous or bony ankylosis Criteria of stage III * The criteria with an asterisk are those that must be present in order to permit classification of a patient in any particular stage or grade.


Prognosis 1 Predictors of poor outcomes in the early stages of rheumatoid arthritis include a relatively low functional score early in the disease progression, lower socioeconomic status, lower education level, strong family history of the disease, and early involvement of many joints. Prognosis is worse in patients who have a high ESR or CRP level at disease onset, positive rheumatoid factor, or early radiologic changes Thirty percent of patients with rheumatoid arthritis, usually those with the most severe forms of the disease, will not demonstrate an ACR 20 response to any treatment Patients with milder disease tend to benefit from early treatment


Treatment 1 It is imperative to diagnose the disease and initiate treatment as soon as possible D isease -modifying antirheumatic drugs (DMARDs ) Anti-inflammatories Corticosteriods Physical Therapy with goals that include preservation of function and quality of life, minimization of pain and inflammation, joint protection, and control of systemic complications Surgery for severely involved joints

Role of Imaging4,5:

Role of Imaging 4,5 Conventional radiographs are most commonly used to characterize the effects of the disease In a study by Scheel et al, after 7 years, an increase of bone erosions were detected by all imaging modalities. In contrast, clinical improvement and regression of synovitis were seen only with US and MRI. More than one third of erosions previously detected by MRI were seen by CR 7 years later. US and MRI are the best imaging tools to diagnose the treatment early

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ABC ’ s 2 Alignment : MCP subluxation in the ulnar direction Subluxation of the 5 th digit PIP in the ulnar direction Subluxation of the CMC and IP of the thumb in the radial direction Bone Density : General loss of bone density as evidenced by decreased cortices Sclerosis present in all of the DIPs, 5 th PIP, the IP MCP and CMC of the thumb, all of CMC and intercarpal joints. Abnormal texture (thin, fluffy, coarse, smudged trab ) Osteophyte formation at all of the DIPs, thumb IP Cartilage : Joint space narrowing at all DIPs, thumb MCP, and fifth digit PIP. As well as decreased joint space within the carpals. Uniform concentric distribution of degeneration present. Subchondral bone Changes in thickness compared to opposite side Soft Tissue : Soft tissue line displacement around all digits and carpals indicating swelling and joint effusion Elevation and blurring indicating swelling of nearby tissues


MRI 6 MRI is important in the early stages of RA Allows for visualization of synovitis and bone erosion long before radiograph Have shown to be more sensitive than a clinical exam for identifying synovitis Techniques focus on monitoring synovial volume or quality as assessed by vascularity Synovitis enhances on MRI with intravenous gadolinium MRI allows for simultaneous assessment of osseous and soft tissue structures “ Often considered to be the gold standard for synovial imaging ” 5

T1 weighted MRI of MCPs and Distal Radioulnar joint6:

T1 weighted MRI of MCPs and Distal R adioulnar joint 6

Assessment of MRI6:

Assessment of MRI 6 Previous slide shows an MRI pre (a and c) and post (b and d) gadolinium injection for visualization of synovium . Image B shows increase in synovium surrounding both the flexor tendons and MCP joints. Image D shows increase in synovium around the radioulnar joint and around the extensor carpi ulnaris tendon (black arrow)


Questions? What group has been set up to assess the validity and reliability of RA outcome measures? And what have they determined in regards to imaging in RA? How would you differentially diagnose rheumatoid arthirits from systemic lupus erythematosus?


References Rindleisch JA, Muller. Diagnosis and Management of Rheumatoid Arthritis. Am Fam Physician 2005; 72, 6: 1037-1047 McKinnis LN. Fundamentals of musculoskeletal imaging 3 rd edition. Philadelphia: F. A. Davis Company 2010: 55-57. Walker JM, Helewa A. Physical Therapy in Arthritis. Philadelphia: WB Saunders Company 1996: 48-57. Ostergaard M, Szkudlarek M. Imaging in rheumatoid arthritis—why MRI and ultrasonography can no longer be ignored. Scand J Rheumatol. 2003; 32(2):63-73. http://www.ncbi.nlm.nih.gov/pubmed/12737323 . Accessed on June 17, 2011. Med-Versation. Imaging in rheumatoid arthritis. Available at: http://www.medversation.com/medversation/hcp/section/PRE/i06ac3cc7-5961-4082-a37e-0ad429085648.html# . Accessed on June 17, 2011. Farrant JM, O ’ Connor PJ, Grainger AJ. Advanced imaging in rheumatoid arthritis. Skeletal Radiol 2007; 36: 269-279. a.       Klippel J, Crofford L, Stone J, Weyand C, eds. Primer on the Rheumatic Diseases 12 th ed . Atlanta: Arthritis Foundation; 2001.

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