Rheumatoid Arthritis

– A chronic systemic degenerative disease characterized by inflammation of the connective tissues and manifested primarily in and around peripheral joints.

Causes and Incidence

The etiology is unknown, although the disease often is characterized as an autoimmune disorder, and a familial link is suspected. Approximately 6.5 million people in the United States are affected, with women three times more likely than men to be affected. Onset usually occurs between 35 and 50 years of age, although the disease has been diagnosed in children between 8 and 15 years of age.

Disease Process

Joint inflammation begins with congestion and edema of the synovial membrane and joint capsule, which develops into synovitis. Thickened layers of granulation tissue invade and destroy the cartilage and joint capsule. The fibrous granulation tissue deforms, ossifies, occludes, and immobilizes the joint. Eventually the disease spreads to major organ systems, including the heart, lungs, kidneys, and eyes.

Symptoms

Early
Nonspecific symptoms of fatigue, malaise, low-grade fever, anorexia, weight loss.

Midcourse
Tenderness, pain, and stiffness in affected joints (most often the fingers) that occurs in a bilateral, symmetric pattern and spreads to the wrists, elbows, knees, and ankles; diminished joint function; paresthesia; joint contractures and deformities.

Late
Subcutaneous rheumatoid nodules, leg ulcers, lymphadenopathy, inflammation and dryness of mucous membranes, episcleritis, pericarditis, valvular lesions, splenomegaly, pneumonitis
Complications: Acute rheumatoid arthritis (ARA) is characterized by abrupt onset and progressive, relentless deterioration of joints and then other major body systems without remission and with poor or no response to medical treatment. The prognosis in these cases is poor.

Diagnostic Tests

Clinical evaluation
ARA: presence of five or more of the following: morning stiffness; pain/tenderness in at least one joint; swelling in at least one joint; symmetric joint swelling; fatigue, malaise, weight loss; paresthesia; Raynaud’s syndrome; subcutaneous nodules; major organ involvement; pericarditis; valvular lesions; vasculitis; pneumonitis; fibrosis; tenosynovitis; ankylosis; Felty’s syndrome (splenomegaly and leukopenia); joint deformities; ulnar drift.

Rheumatoid factor
Positive in 95% of cases.

Synovial analysis
Opaque color; increased volume and turbidity; decreased viscosity and complement; 3,00050,000 WBCs/{micro};l; polymorphonuclear cells predominant.

Erythrocyte sedimentation rate
Elevated in 90% of cases.

Complete blood count
Hypochromic anemia, elevated WBCs.

Radiology
Soft tissue swelling, narrowed joint space, marginal erosions.

Treatments

Surgery
Synovectomy for pain relief; repair of ruptured tendon sheaths to prevent deformity and subluxation; osteotomy to change weight-bearing surfaces; total joint replacement to increase mobility.

Drugs
Aspirin, nonsteroidal antiinflammatory drugs, gold compounds/penicillamine to reduce pain and inflammation; oral or intraarticular injections of corticosteroids to reduce inflammation; immunosuppressive/antineoplastic agents.

General
Whirlpool, moist compresses, paraffin gloves to reduce pain and edema; therapy and exercise to increase range of motion, strength, and endurance; balance of activity and rest; splints, canes, walkers to aid mobility; emotional support to adapt to disability.