Rheumatoid Arthritis ~ Pureheal96

Rheumatoid Arthritis (RA):

When the body’s defense mechanism attacks own cells considering it as an antigen is termed as autoimmune condition.

Rheumatoid Arthritis is one of the chronic systemic auto-immune diseases which attacks the tissues of lining of joints. It causes painful swelling.

Mainly it affects big joints at first i.e., knees, elbows or both wrists. Rheumatoid Arthritis with duration of less than 6 months is defines as early, and if symptoms have been present for more than months is established.

Aetiology:

Yet, no aetiology is known for the disease.

Hereditary chances is 40%- 65% for seropositive RA and 20% for seronegative RA.

Genes which is related to RA is HLA-DRB1 alleles.

Incidences are higher in Northern Europe and North America. Female male ratio is 3:1, prevalence increases by age.

Pathophysiology:

Antibodies are produced against protein known as citrullinated proteins. These antibodies are known as Anti-Citrullinated Protein Antibodies (ACPA). These antibodies lead to severe joint damage and even results into high mortality rate.

ACPA is present in serum for up to 10 years before the onset of the symptoms and the count increases with the age.

Symptoms:

· Patient complaints of monoarticular joint involvement. Commonly affected joints are wrists, elbows, shoulders, hips, knees, ankles and metatarsophalangeal joints.

· Stiffness in joints in morning, lasts up to several hours, more than 1 hour at least. Patient have trigger finger.

· On examination: Swelling, tenderness, deformities and restricted movements are present.

· Rheumatoid nodules in 20% of the patient, present in extensor surface of elbow, heals and toes.

· Swan neck deformities is present in late course of the disease.

· Others: Carpel tunnel syndrome, tenosynovitis and finger deformities

· Rheumatoid Arthritis also affects skin, heart, lungs or kidneys.

Work-up:

· RA factor: Positive in 45%-75% of the patients. But this is not the diagnostic test.

· ACPA: Positive in 50% of the patients with early stage of arthritis.

· ESR and CRP is elevated in active phase.

· X-ray of hands and feet for evaluation of the erosion. At early stage, no changes are seen in x-ray.

· MRI or USG of joints are more sensitive than x-ray.

Treatment and Management:

· Disease Modifying Anti-Rheumatic Drugs (DMARDs) are started as soon as RA is detected.

Conventional DMARDs- Methotrexate, Leflunomide, Sulfasalazine, HCQ. Biological DMARDs- Adalimumab, Etanercept, Infliximab, Golimumab, Cetrolizumab.

· Non- TNF-inhibitars: Tocilizumab, Rituximab, Abatacept.

Differential Diagnosis:

· Lupus

· Chronic Lyme disease

· Osteoarthritis

· Septic arthritis

· Psoriatic arthritis

· Sjorgen syndrome

· Sarcoidosis

Prognosis:

No curative treatment is known yet. The disease is progressive. Patient disable within 10 years.

Worse prognosis can be determined by:

· Elevated serum titre of autoantibodies.

· Presence of HLA_DRB1*04 genotype.

· Involvement of multiple joints.

· Extra-articular features.

· Female gender.

· Less than 30 years of age.

· Insidious onset.

· Presence of systemic symptoms.

Also, the disease is associated with cardio- vascular disease, infection, respiratory disease, and malignancy. Death ratio increases to 2-3 times higher compared to general population.

Complications:

· Infection

· Chronic anemia

· Gastrointestinal cancer

· Pleural effusion

· Osteoporosis

· Heart disorder

· Sicca syndrome

· Lymphoma