Rheumatoid Arhritis

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Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, joint pain, and often destruction of joints.

• The immune system damages the joints and connective tissues
• Joints (typically the small joints of the limbs) become painful and have stiffness that persists for more than 60 minutes on awakening and after inactivity
• Fever, weakness, and damage to other organs may occur
• Electromyography, blood tests, and imaging tests are needed to confirm the diagnosis.
• Diagnosis is based mainly on symptoms, but also on blood tests for rheumatoid factor and on x-rays
• Treatment can include exercises and splinting, drugs (nonsteroidal anti-inflammatory drugs [NSAIDs], disease-modifying antirheumatic drugs, and immunosuppressive drugs), and surgery.

Worldwide, rheumatoid arthritis develops in about 1% of the population, regardless of race or country of origin, affecting women 2 to 3 times more often than men. Usually, rheumatoid arthritis first appears between 35 years and 50 years of age, but it may occur at any age. A disorder similar to rheumatoid arthritis can occur in children. The disease is then called juvenile idiopathic arthritis, and the symptoms and prognosis are often somewhat different.

The exact cause of rheumatoid arthritis is not known. It is considered an autoimmune disease. Components of the immune system attack the soft tissue that lines the joints and can also attack connective tissue in many other parts of the body, such as the blood vessels and lungs. Eventually, the cartilage, bone, and ligaments of the joint erode, causing deformity, instability, and scarring within the joint. The joints deteriorate at a variable rate. Many factors, including genetic predisposition, may influence the pattern of the disease. Unknown environmental factors (such as viral infections) are thought to play a role.

Symptoms

People with rheumatoid arthritis may have a mild course, occasional flare-ups with long periods of remission (in which the disease is inactive), or a steadily progressive disease, which may be slow or rapid. Symptoms of rheumatoid arthritis may start suddenly, with many joints becoming inflamed at the same time. More often, it starts subtly, gradually affecting different joints. Usually, the inflammation is symmetric, with joints on both sides of the body affected about equally. Typically, the small joints in the fingers, toes, hands, feet, wrists, elbows, and ankles become inflamed first. The inflamed joints are usually painful and often stiff, especially just after awakening (such stiffness generally lasts for more than 60 minutes) or after prolonged inactivity. Some people feel tired and weak, especially in the early afternoon. Rheumatoid arthritis may cause a loss of appetite with weight loss and a low-grade fever.

Affected joints are tender, warm, red, and enlarged because of swelling of the soft tissue and sometimes fluid within the joint. Joints can quickly become deformed. Joints may freeze in one position so that they cannot bend or open fully. The fingers may tend to dislocate slightly from their normal position toward the little finger on each hand, causing tendons in the fingers to slip out of place.

Swollen wrists can pinch a nerve and result in numbness or tingling due to carpal tunnel syndrome. Cysts, which may develop behind affected knees, can rupture, causing pain and swelling in the lower legs. Up to 30% of people with rheumatoid arthritis have hard bumps (called rheumatoid nodules) just under the skin, usually near sites of pressure (such as the back of the forearm near the elbow).

Rarely, rheumatoid arthritis causes an inflammation of blood vessels (vasculitis). This condition reduces the blood supply to tissues and may cause nerve damage or leg sores (ulcers). Inflammation of the membranes that cover the lungs (pleura) or of the sac surrounding the heart (pericardium) or inflammation and scarring of the lungs or heart can lead to chest pain or shortness of breath. Some people develop swollen lymph nodes; Sjögren's syndrome, which consists of dry eyes, mouth, vagina, or a combination; or red, painful eyes caused by inflammation (episcleritis).

Diagnosis

In addition to the important characteristic pattern of symptoms of arthritis, the doctor may use the following to support the arthritis diagnosis: laboratory tests, an examination of a joint fluid sample obtained with a needle, and even a biopsy (removal of a tissue sample for examination under a microscope) of rheumatoid nodules. Characteristic changes in the joints may be seen on x-rays. Magnetic resonance imaging (MRI) seems to be more sensitive and detects joint abnormalities earlier but is not usually necessary for making the diagnosis.

Blood Tests: In 9 of 10 people who have rheumatoid arthritis, the erythrocyte sedimentation rate (ESR—a test that measures the rate at which red blood cells settle to the bottom of a test tube containing blood) is increased, which suggests that active inflammation is present. However, similar increases in the ESR occur in many other disorders. Doctors may monitor the ESR to help determine whether the disease is active.

Many people with rheumatoid arthritis have distinctive antibodies in their blood, such as rheumatoid factor, which is present in 70% of people with rheumatoid arthritis. (Rheumatoid factor also occurs in several other diseases, such as hepatitis and some other infections. Some people even have rheumatoid factor in their blood without any evidence of disease.) Usually, the higher the level of rheumatoid factor in the blood, the more severe the rheumatoid arthritis and the poorer the prognosis. The rheumatoid factor level may decrease when joints are less inflamed.

Anti-citrullinated peptide (anti-CCP) antibodies are present in 96% of people who have rheumatoid arthritis and are almost always absent in people who do not have rheumatoid arthritis. Doctors are starting to use tests for anti-CCP antibodies to help diagnose rheumatoid arthritis.

Most people have mild anemia (an insufficient number of red blood cells). Rarely, the white blood cell count becomes abnormally low. When a person with rheumatoid arthritis has a low white blood cell count and an enlarged spleen, the disorder is called Felty's syndrome.

Prognosis

The course of rheumatoid arthritis is unpredictable. The disorder progresses most rapidly during the first 6 years, particularly the first year, and 80% of people develop permanent joint abnormalities within 10 years. Rheumatoid arthritis may decrease life expectancy by 3 to 7 years. Heart disease, infection, gastrointestinal bleeding, drug treatment, cancer, and the underlying disease may be responsible. Rarely, rheumatoid arthritis resolves spontaneously.

Treatment relieves symptoms in 3 of 4 people; however, at least 10% are eventually severely disabled despite full treatment. Factors that tend to predict a poorer prognosis include the following:

• Being white, a woman, or both
• Having rheumatoid nodules
• Being older when the disorder begins
• Having inflammation in 20 or more joints
• Having a high ESR
• Having high levels of rheumatoid factor or anti-CCP

Treatment

Individual treatment for arthritis may vary depending upon the patient and their desire to receive tradition treatment, alternative treatment or integrative treatment for the disease.  It is vital that persons diagnosed with, or suspected of having rheumatoid arthritis consult with their health care provider to assure proper evaluation, treatment and interpretation of information contained on this site.

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