Rheumatology Book

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Rheumatoid Arthritis

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  1. See Also
    1. Rheumatoid Arthritis Diagnosis
    2. Rheumatoid Arthritis Articular Signs
    3. Rheumatoid Arthritis Extra-articular Signs
    4. Felty's Syndrome
    5. Rheumatoid Arthritis Management
    6. Rheumatoid Arthritis Antiinflammatory Medications
    7. Rheumatoid Arthritis Remittive Agents
  2. Epidemiology
    1. Prevalence: 0.3 - 1.5% of population
    2. Women affected 2-3x more often
    3. Twin concordance: 30 to 50%
    4. Peak Incidence ages 40 to 60 years
    5. Associated with HLA-DR4 and HLA-DR1 haplotypes
  3. Pathophysiology: Order of changes
    1. Synovial Macrophage and fibroblast activation
    2. Cytokine production (interleukin, TNF)
    3. Lymphoctes infiltrate perivascular areas
    4. Synovial thickening (Pannus formation and spread)
    5. Neovascularization
    6. Local micro-Vasculitis
    7. Chondrocyte, Osteoclast, CD4+ Helper activity
    8. Endothelial proliferation
    9. Joint space narrowing
    10. Cytokine release (resulting in fever, Anemia)
  4. Risk Factors
    1. Increased risk
      1. Female gender
      2. Family History of rheumatoid arthritis
      3. Tobacco abuse
      4. More than 3 cups coffee daily (esp. decaffeinated)
    2. Decreased risk
      1. Oral Contraceptive use
      2. Increased Vitamin D intake
      3. Tea intake
    3. References
      1. Kuder (2002) Rev Environ Health 17:307
  5. Course
    1. Self-limited (5-20%)
    2. Minimally progressive (5-20%)
    3. Progressive (60-90%)
      1. Early damage
        1. Two Years from onset:
          1. Joint space narrowing and Erosions in 50%
        2. Ten years from onset:
          1. Young working patients are disabled: 50%
      2. Early death by multiple causes
        1. Women's life expectancy reduced by 10 years
        2. Men's life expectancy reduced by 4 years
  6. Diagnosis
    1. See Rheumatoid Arthritis Diagnosis
    2. See Rheumatoid Arthritis Articular Signs
    3. See Rheumatoid Arthritis Extra-articular Signs
  7. Differential Diagnosis
    1. See Polyarthritis
    2. Arthropathy of Inflammatory Bowel Disease
    3. Hemochromatosis
    4. Hepatitis B
    5. Hypothyroidism
    6. Fibromyalgia
    7. Gouty Arthritis (polyarticular)
    8. Parvovirus
    9. Polymyalgia Rheumatica
    10. Psoriatic Arthritis
    11. Reiter's Syndrome
    12. Sarcoidosis
    13. Scleroderma
    14. Still's Disease
    15. Subacute Bacterial Endocarditis
    16. Systemic Lupus Erythematosus
  8. Labs (ARA recommended, but do not exclude diagnosis)
    1. Initial Labs
      1. Complete Blood Count with differential
      2. Rheumatoid Factor (Initially positive in 70%)
      3. Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
    2. Additional labs in preparation for rheumatic agents
      1. Liver Function Tests
      2. Renal Function tests
      3. PPD with candida controls (before Steroids or DMARDs)
    3. Markers of disease course
      1. C-Reactive Protein (C-RP)
      2. Erythrocyte Sedimentation Rate
      3. Wrist XRay or Ankle XRay
      4. Anticyclic citrullinated peptide Antibody
  9. Radiology
    1. See Rheumatoid Arthritis Related XRay Changes
    2. Chest XRay (Erosions define moderate to severe disease)
  10. Management
    1. Rheumatoid Arthritis Management
    2. Rheumatoid Arthritis Antiinflammatory Medications
    3. Rheumatoid Arthritis Remittive Agents
  11. Prognosis: Poor Prognostic Signs
    1. Hyper-acute onset (overnight onset)
    2. Multiple joint involvement (especially >20 joints)
    3. High titer Rheumatoid Factor (RF)
    4. HLA-DRBI 0404
    5. Low dose Corticosteroid resistance
    6. Early loss of function or young age of onset
    7. Higher Erythrocyte Sedimentation Rate
    8. Rheumatoid Arthritis Extra-articular Signs
  12. References
    1. Pincus (1993) Rheum Dis Clin North Am 19:123

Rheumatoid Arthritis (C0003873)

Definition (MSH)A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated.
Definition (CSP)chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures; etiology is unknown, but autoimmune mechanisms have been implicated.
Definition (NCI)A chronic systemic disease, primarily of the joints, marked by inflammatory changes in the synovial membranes and articular structures, widespread fibrinoid degeneration of the collagen fibers in mesenchymal tissues, and by atrophy and rarefaction of bony structures. Etiology is unknown, but autoimmune mechanisms have been implicated.
ConceptsDisease or Syndrome (T047)
ICD9714.0, 714.0
MSHD001172
EnglishARTHRITIS RHEUMATOID, Atrophic arthritis, Chronic rheumatic arthritis, RA, RA - Rheumatoid arthritis, RhA - Rheumatoid arthritis, Rheumatic gout, Rheumatoid Arthritis, Rheumatoid disease
Spanishartritis atrofica, artritis reumatica cronica, artritis reumatoide, gota reumatica
Parent ConceptsInflammatory polyarthritis (C1692871), [X]Inflammatory polyarthropathies (C1692324), Arthritis (C0003864), Autoimmune Diseases (C0004364), Arthropathies NOS (C0022408), COLLAGEN VASCULAR DISEASE (C0262428), Multiple Organ Syndromes NEC (C0549513), Rheumatoid arthritis and other inflammatory polyarthropathies (C0157913), Rheumatism (C0035435), Rheumatologic Disorder (C0748408), Rheumatoid Arthritis (C0003873), Arthropathy associated with a hypersensitivity reaction (C0263730), Duplicate concept (C1274013), Delayed hypersensitivity disorder (C1960693)
SourcesAIR, AOD, COSTAR, CSP, CST, DXP, ICD9CM, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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