{"id":8430,"date":"2021-11-25T19:22:33","date_gmt":"2021-11-25T17:22:33","guid":{"rendered":"https:\/\/meddists.com\/learn\/clinical\/rheumatology\/rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment\/"},"modified":"2022-04-21T19:54:04","modified_gmt":"2022-04-21T17:54:04","slug":"rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment","status":"publish","type":"page","link":"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/rheumatology\/rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment\/","title":{"rendered":"Rheumatoid arthritis: clinical symptoms and signs, diagnosis and treatment"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Rheumatoid arthritis (RA) is a chronic inflammatory disease that mostly affects the joints, among other tissues.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>RA is characterized by a symmetrical and bilateral inflammation of the synovium of joints, with progressive erosion and destruction of the affected joints.<\/li><li>Virtually every joint can be affected apart from the distal interphalangeal joints (DIP).<\/li><li><strong>Epidemiology<\/strong>. Population prevalence of 0.5% to 1% and an annual incidence of 12-1,200 per 100,000 population. Females are more commonly affected.<\/li><li><strong>Etiology<\/strong>. RA is a complex multifactorial (genetic and environmental) disease with an uncertain etiology.<ul><li><strong>Environmental<\/strong>. Associated with smoking and periodontitis.<\/li><li><strong>Genetics<\/strong>. HLA-DR1 and HLA-DR4 genes.<\/li><\/ul><\/li><\/ul>\n\n\n<span class=\"block-heading\" id=\"header_1\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Clinical presentation<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_1\">\n\n<\/span><span class=\"block-heading\" id=\"header_2\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Course pattern<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_2\">\n\n\n<p class=\"wp-block-paragraph\">RA typically appears in one of three course patterns:<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Single attack with complete remission (monocyclic)<\/li><li>Remittent attacks with complete or incomplete remission periods (polycyclic, most common)<\/li><li>Progressive disease without remissions<\/li><\/ol>\n\n\n<\/span><span class=\"block-heading\" id=\"header_3\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Disease course<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_3\">\n\n\n<ul class=\"wp-block-list\"><li>Early disease presents with general symptoms (weakness, fever, malaise), and joint swelling and pain. Synovitis and joint erosion are evident in radiographic imaging.<\/li><li>Remission periods may occur, with limited to no disease activity.<\/li><li>As the disease progresses, additional joints usually become affected, with worsening of the symptoms with irreversible joint damage (seen as synovial proliferation and granulation tissue or <strong>pannus formation<\/strong>).<\/li><li>Complete joint destruction with severe movement limitation and disability (seen as <strong>ankylosis<\/strong>).<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_4\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Early disease<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_4\">\n\n\n<ul class=\"wp-block-list\"><li>Typically, starts with the joints of the hands and wrists, feet, knees, and shoulders. The joints are symmetrically swollen and painful. <ul><li>During physical examination, the pain is evoked by pressing the MCP (MCP compression test).<\/li><li>Muscle pain and fatigue may also be present.<\/li><li>Passive movements cause pain.<\/li><li>The skin might be warm, but <strong>without <\/strong>erythema (erythema probably means PsA or infection).<\/li><\/ul><\/li><li>Larger joints (knee, elbow, neck, rarely the axial skeleton) are typically affected later on.<\/li><li>Patients typically experience morning stiffness that lasts for several hours.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_5\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Joint involvement<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_5\">\n\n\n<p class=\"wp-block-paragraph\">The involved joints are affected symmetrically, although this may not always be evident.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Hand and wrist joints.<\/strong> <ul><li>The most commonly affected joints are the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints.<\/li><li>Late-stage changes include:<ul><li><strong>Swan-neck deformity.<\/strong> PIP extension, and DIP flexion.<\/li><li><strong>Buttonhole (Boutonniere) deformity.<\/strong> PIP flexion, and DIP extension.<\/li><li><strong>Ulnar deviation at the MCP joints<\/strong> with dorsal interosseous muscle atrophy.<\/li><\/ul><ul><li><strong>Piano-key sign.<\/strong> Instability of the inferior radioulnar joint along with pain.<\/li><li>Carpal tunnel syndrome due to the compression of the median nerve.<\/li><li>Damage to the extensor tendons at the wrist may lead to rupture of tendons IV-V, nodule formation (which leads to &#8220;trigger finger&#8221;).<\/li><\/ul><\/li><\/ul><\/li><li><strong>Knee joints<\/strong><ul><li>Inflammation of the knee joint may result in <strong>Baker&#8217;s cyst<\/strong>; an accumulation of synovial fluid in the posterior part of the knee seen as a swelling of the popliteal fossa.<\/li><\/ul><ul><li>A ruptured Baker&#8217;s cyst may imitate DVT; ultrasound should be done and anticoagulant therapy should not be administered! <\/li><\/ul><\/li><li><strong>Foot and ankle joints<\/strong>. Metatarsophalangeal (MTP) joints are usually affected.<ul><li>Late-stage changes include:<ul><li>Hallux valgus<\/li><li>Deviation of the 2nd-5th toes towards the fibula<\/li><li>Hammer toes<\/li><\/ul><\/li><\/ul><\/li><li><strong>Temporomandibular joints<\/strong>. Painful chewing.<\/li><li><strong>Cervical spine<\/strong>. Subluxation of the atlantoaxial joint, leading to cervical spine instability, and risking the compression of the spinal cord.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_6\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Extra-articular manifestations<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_6\">\n\n\n<ul class=\"wp-block-list\"><li><strong>Rheumatoid nodules<\/strong>. Skin lesions appearing on extensor surfaces, most commonly on the elbow, typically seen in late disease.<\/li><li>Microscopic vasculitis (typically around the nail bed)<\/li><li>Reynaud&#8217;s phenomenon<\/li><li>Dry pleuritis, pneumothorax<\/li><li>Pericarditis, pericardial effusions<\/li><li>Keratoconjunctivitis sicca<\/li><li>Lymphadenopathy<\/li><li>Anemia of chronic inflammation<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_7\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Diagnosis<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_7\">\n\n\n<ul class=\"wp-block-list\"><li>Blood tests (CRP, ESR)<\/li><li>Serology (RF, ACPA)<\/li><li>US (erosions)<\/li><li>X-ray (erosions of the 5th metatarsal head early on)<\/li><li>The <strong>ACR-EULAR classification criteria <\/strong>is a scoring system based on joint symptoms (number), serology, duration (over or under 6 weeks), and acute phase reactants (CRP, ESR).<\/li><li>DAS28 (disease activity score) measures the activity of the disease, checking 28 joints, and is a simplified version of DAS44 (which checks 44 joints).<\/li><li>Synovial fluid or histological examination has no diagnostic value.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_8\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Treatment<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_8\">\n\n\n<p class=\"wp-block-paragraph\">The treatment should be started as soon as possible, as the majority of joint damage occurs early in the disease.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>NSAIDs<\/li><li>Corticosteroids<\/li><li>Methotrexate\/leflunomide initiated early<\/li><li>If monotherapy fails, combine with a second DMARD such as antimalarials, sulfasalazine<\/li><li>Depending on the treatment protocol: infliximab, rituximab<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_9\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">References<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_9\">\n\n\n<ol class=\"wp-block-list\"><li>Smithson J.&nbsp;<em>Rheumatoid Arthritis.<\/em>&nbsp;Pharmaceutical Society Of Australia, Oct; 2009.<\/li><\/ol>\n<\/span><div id=\"the_titles\" style=\"display:none;\"><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Clinical presentation<\/h3><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Course pattern<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Disease course<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Early disease<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Joint involvement<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Extra-articular manifestations<\/h4><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Diagnosis<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Treatment<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">References<\/h3><\/div>","protected":false},"excerpt":{"rendered":"<p>Rheumatoid arthritis (RA) is a chronic inflammatory disease that mostly affects the joints, among other tissues. RA is characterized by a symmetrical and bilateral inflammation of the synovium of joints, with progressive erosion and destruction of the affected joints. Virtually every joint can be affected apart from the distal interphalangeal joints (DIP). Epidemiology. Population prevalence [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":8424,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-8430","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Rheumatoid arthritis: clinical symptoms and signs, diagnosis and treatment &#8211; Meddists<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/rheumatology\/rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment\/\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/rheumatology\\\/rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment\\\/\",\"url\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/rheumatology\\\/rheumatoid-arthritis-clinical-symptoms-and-signs-diagnosis-and-treatment\\\/\",\"name\":\"Rheumatoid arthritis: clinical symptoms and signs, diagnosis and treatment &#8211; 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