1. Rheumatoid Arthritis(RA)

2. Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder that may affect many tissues and organs—skin, blood vessels, heart, lungs, and muscles—but principally attacks the joints, producing a non-suppurative proliferative and inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints.

3. Although the cause of RA remains unknown, autoimmunity plays a pivotal role in its chronicity and progression.
About 1% of the world's population is afflicted by RA, women two to three times more often than men. It is most common in those age 40 to 70, but no age is immune.

4. :* Pathophysiology Unknown antigen stimulates CD4+ T lymphocytes.
Active CD4+ T lymphocytes;
stimulates macrophages to release IL1 and TNF.
Release RANKL which stimulates osteoclasts leading to bone destruction.
IL-1 and TNF stimulates synovial cells leading to:
Synovial cell proliferation and formation of pannaus.
Production of prostaglandins (pain sensation) and matrix metalloproteinases that cause cartilage destruction.

6. * Sequence of events :
Proliferation of synovial membrane cells with inflammatory cell infiltrate
Destruction of joints
Disability

7. * Diagnosis: 1. Clinical manifestations. 2. Investigations.

8. 1. Clinical manifestations

9. Articular manifestations:
Symmetric peripheral polyarthritis
Morning Stiffness >1 hour
Extra-articular manifestations:

10. Symmetric peripheral polyarthritis:
3 or more Joints for >6 weeks
Small Joints
Hands & feets
Peripheral to Proximal
Leads to deformity & destruction of Joints.

11. Morning stiffness: Morning or after Prolonged Inactivity. Bilateral
> 1 hour.
Better with movement
Pain with movement of joint

12. Physical Examination:
Decreased grip strength
Carpal tunnel syndrome(condition characterized by pain and numbing or tingling sensations in the hand and caused by compression of a nerve in the carpal tunnel at the wrist.
Ulnar deviation

13. * Extra-articular manifestations:
Myalgia, fatigue, low-grade fever, weight loss, depression.
Anemia
Rheumatoid nodules
Pleuropericarditis
Neuropathy
Scleritis
Splenomegaly
Vasculitis

14. Rheumatoid Nodules Extensor surfaces especially elbows Very Specific
Only occur in ~30%
Late in Disease

15. 2. Investigations

16. 1. Arthrocentesis. 2. Arthroscopy.
Evaluate ligamentous & cartilaginous integrity
Biopsy

17. Rheumatoid arthritis showing inflammatory cell infiltrate in the synovium

18. 3. Laboratory investigations:
Rhumatoid Factor:
Positive in 70-80% of patients.
- - IgM or IgG
- If IgM+ve : more severe disease & poorer outcome.
Acute Phase reactants:
ESR, CRP  monitoring disease activity

19. 4. Radiology: Evaluate disease activity & joint damage. Plain Films.
Color Doppler U/S & MRI

22. Disease Severity

23. Mild case Arthralgias >3 inflamed joints Mild functional limitation
Minimally elevated ESR & CRP
No erosions/cartilage loss
No extra-articular manifestations.

24. Moderate case 6-20 Inflamed joints Moderate functional limitation
Elevated ESR/CRP
Radiographic evidence of inflammation
No extra-articular manifestations.

25. Severe case >20 persistently inflamed joints
Rapid decline in functional capacity
Radiographic evidence of rapid progression of bony erosions & loss of cartilage
Extra-articular manifestations.

26. Bad prognostic Features
RF +ve
Early development of multiple inflamed joints.
Severe functional limitation
Lower socioeconomic status & Less education
Persistent joint inflammation for >12 weeks