Rheumatoid Arthritis

RHEUMATOID ARTHRITIS 45A

A 47-year-old woman presents to the clinic with a 4-week history of fatigue, bilateral hand pain and stiffness, and hand and wrist joint swelling. About 1 month before presentation, she noticed that her hands were stiffer in the morning but thought that it was because of too much typing. However, the stiffness has worsened, and she now needs about 1 hour each morning to “loosen up” her hands. As the day goes on, the stiffness improves, although it does not go away entirely. She has also noticed that her knuckles and wrists are swollen and feel somewhat warm. Physical examination reveals warm, erythematous wrists and metacarpal joints bilaterally. Hand radiographs show periarticular demineralization and erosions, and blood test results are significant for mild anemia, elevated erythrocyte sedimentation rate (ESR), and positive rheumatoid factor (RF) and anti-CCP (anti–cyclic citrullinated protein) antibodies.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Polyarticular joint pain and swelling; stiffness worse in the morning and lasting more than 30 minutes; wrist and metacarpophalangeal (MCP) joint involvement; bilaterality of joint involvement; radiographs with demineralization and erosions; elevated ESR and rheumatoid factor and anti-CCP antibodies.

How to think through: Is this arthralgia (joint pain) or arthritis (joint inflammation)? What four things indicate joint inflammation (rubor [redness], dolor [pain], calor [warmth], tumor [swelling])? How many joints are involved (mono- vs. oligo- vs. polyarthritis)? What is the pattern of joint involvement: small versus large versus both? Which joints are involved (distal interphalangeal [DIP] vs. proximal interphalangeal [PIP] vs. MCP)? Is there morning stiffness for at least 30 minutes and prominent afternoon fatigue? Are there features of lupus (sicca symptoms, oral ulcers, malar rash, photosensitivity, chest pain, or Raynaud phenomenon)? Are there symptoms of psoriasis or inflammatory bowel disease? ESR, although nonspecific, is useful marker of inflammation in subtle cases. A positive RF result and characteristic erosions on hand radiographs strengthen the case for rheumatoid arthritis (RA), and positive anti-CCP antibodies are highly specific for the diagnosis. Would arthrocentesis help? If so, what might the synovial fluid show in this patient?

RHEUMATOID ARTHRITIS 45B

What are essentials of diagnosis and general considerations regarding rheumatoid arthritis?

Essentials of Diagnosis

Insidious onset with morning stiffness and symmetric joint pain

Polyarthritis with predilection for the small joints of the hands and feet

Radiographic juxtaarticular osteoporosis; joint erosions and narrowing

RF and anti-CCP antibodies in 70% to 80%

Extraarticular manifestations, including subcutaneous nodules, interstitial lung disease, pleural effusion, pericarditis, splenomegaly with leukopenia, vasculitis