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Rheumatoid Arthritis
- See Also
- Epidemiology
- Prevalence: 0.3 - 1.5% of population
- Women affected 2-3x more often
- Twin concordance: 30 to 50%
- Peak Incidence ages 40 to 60 years
- Associated with HLA-DR4 and HLA-DR1 haplotypes
- Pathophysiology: Order of changes
- Synovial Macrophage and fibroblast activation
- Cytokine production (interleukin, TNF)
- Lymphoctes infiltrate perivascular areas
- Synovial thickening (Pannus formation and spread)
- Neovascularization
- Local micro-Vasculitis
- Chondrocyte, Osteoclast, CD4+ Helper activity
- Endothelial proliferation
- Joint space narrowing
- Cytokine release (resulting in fever, Anemia)
- Risk Factors
- Increased risk
- Female gender
- Family History of rheumatoid arthritis
- Tobacco abuse
- More than 3 cups coffee daily (esp. decaffeinated)
- Decreased risk
- Oral Contraceptive use
- Increased Vitamin D intake
- Tea intake
- References
- Increased risk
- Course
- Self-limited (5-20%)
- Minimally progressive (5-20%)
- Progressive (60-90%)
- Early damage
- Two Years from onset:
- Joint space narrowing and Erosions in 50%
- Ten years from onset:
- Young working patients are disabled: 50%
- Two Years from onset:
- Early death by multiple causes
- Women's life expectancy reduced by 10 years
- Men's life expectancy reduced by 4 years
- Early damage
- Diagnosis
- Differential Diagnosis
- See Polyarthritis
- Arthropathy of Inflammatory Bowel Disease
- Hemochromatosis
- Hepatitis B
- Hypothyroidism
- Fibromyalgia
- Gouty Arthritis (polyarticular)
- Parvovirus
- Polymyalgia Rheumatica
- Psoriatic Arthritis
- Reiter's Syndrome
- Sarcoidosis
- Scleroderma
- Still's Disease
- Subacute Bacterial Endocarditis
- Systemic Lupus Erythematosus
- Labs (ARA recommended, but do not exclude diagnosis)
- Initial Labs
- Complete Blood Count with differential
- Rheumatoid Factor (Initially positive in 70%)
- Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
- Additional labs in preparation for rheumatic agents
- Liver Function Tests
- Renal Function tests
- PPD with candida controls (before Steroids or DMARDs)
- Markers of disease course
- C-Reactive Protein (C-RP)
- Erythrocyte Sedimentation Rate
- Wrist XRay or Ankle XRay
- Anticyclic citrullinated peptide Antibody
- Initial Labs
- Radiology
- See Rheumatoid Arthritis Related XRay Changes
- Chest XRay (Erosions define moderate to severe disease)
- Management
- Prognosis: Poor Prognostic Signs
- Hyper-acute onset (overnight onset)
- Multiple joint involvement (especially >20 joints)
- High titer Rheumatoid Factor (RF)
- HLA-DRBI 0404
- Low dose Corticosteroid resistance
- Early loss of function or young age of onset
- Higher Erythrocyte Sedimentation Rate
- Rheumatoid Arthritis Extra-articular Signs
- References
