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rha

rheumatoid arthritis

epidemiology

  • F:M = 3:1; esp. 4th-6th decades; 20% have an acute presentation; inflammation increased by movement!
  • esp. if HLA-DR4; Rh factor +ve in 70%;
  • US study of 76,000 women aged 50-79 years presented in 20101) suggests that drinking tea increase risk of RhA by 40%, and drinking > 4 cups a day increases risk by 70%. Given the nature of the study, it is also perhaps plausible that women with Rh A drank more tea in the belief that it decreases arthritis. Risk of RhA in this study was not related to caffeine intake or coffee.

joints involved

  • MCPs, PIPs, wrists
    • ⇒ ulnar deviation - subluxation of ext. tendons at MCP jts
    • ⇒ swan-neck - PIP hyperextension & compensatory DIP flexion due to IO contractures &/or shortening of extensor tendons
    • ⇒ boutonniere deformities - PIP fixed flexion contracture with DIP hyperextension due to division of extensor hood with volar slipping of ext. tendon from middle phalanx
    • ⇒ limited dorsiflexion wrist
    • ⇒ z-deformity thumb - MCP flexion & IP hyperextension due to:
      • prolapse of MC head b/n the long & short extensore tendons, or,
      • rupture of thumb flexor
  • knees, ankles
    • ⇒ muscle atrophy, Baker's cyst, retrocalcaneal bursae
  • 1st & 5th MTPs, subtalar/midtarsal joints
  • cervical spine
    • ⇒ degeneration of transverse ligt of atlantoaxial jt
  • TMJs
    • ⇒ pain on chewing
  • cricoarytenoids
    • ⇒ hoarseness

extra-articular features:

  • tenosynovitis
  • s/c nodules
    • esp. elbows
  • vasculitis
    • ⇒ skin infarcts
  • pulmonary disease:
    • pleurisy, effusions
    • fibrosing alveolitis, interstitial fibrosis,
    • bronchiolitis obliterans
    • pulm. arteritis/hypertension
    • nodules ⇒ cavitation/bronchopleural fistulae/Caplan's syndrome
    • stridor due to crycoarytenoid arthritis or nodules on cords
    • recurrent infections (Sjogren's)
    • iatrogenic: asthma (aspirin)/ allergic finrosing alveolitis (gold); Goodpasture's (penicillamine); interstitial fibrosis (methotrexate, chlorambucil)
  • mononeuritis multiplex
  • Felty's syndrome:
    • seropos. RhA + splenomegaly + neutropenia ⇒ infections, etc
  • ocular:
    • keratoconjunctivitis sicca (in 20-30%) / Sjogren's syndrome
    • episcleritis / scleritis / scleromalacia perforans / scleral nodules &/or vasculitis
    • iatrogenic: corneal opacity/pigmentary retinopathy (chloroquine); cataracts (steroids);
  • cardiac:
    • acute pericarditis;
    • insignificant MR;
    • AR due to vasculitis or nodules;
  • renal disease:
    • amyloidosis (nephrosis)
    • renal tubular acidosis (in Sjogren's)
    • analgesic nephropathy
    • NSAID-induced usually benign interstitial nephritis ⇒ haematuria +/- proteinuria
    • other iatrogenic: gold/penicillamine: reversible proteinuria/nephrosis/Goodpasture's;
  • splenomegaly due to:
    • primary disease manifestation (normal neutrophil count)
    • Felty's syndrome (neutropenia)
    • Sjogren's syndrome
    • amyloidosis
  • anaemia due to:
    • active inflammatory “chronic” disease
    • Felty's syndrome
    • iatrogenic - GIT bleed; hypoplastic anaemia; sulphasalazine haemolysis or folate defic.

disease modifying medications

  • parenteral TNF alpha antagonists such as:
    • adalimumab injection every 2wks
    • etanercept
  • Janus kinase inhibitors which block the cytokine pathway which activates lymphocytes, such as:
    • oral tofacitinib 5mg bd
rha.txt · Last modified: 2016/01/11 08:45 by gary1