Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflamma­tory arthritis, affecting from 0.5% to 1% of the general population worldwide. Although RA is primarily considered a disease of the joints, abnormal systemic immune responses are evident and can cause a variety of extra-articular manifestations. The prime target of RA is the synovium considering its vascularity, with subsequent deposition of immune complexes. The cause is unknown, but few factors can trigger its occurrence, i.e., environmental (smoking, bacterial or viral infection) and in genetically susceptible individuals (HLA DR 4). Gender is another factor, with the Female: Male ratio being 3:1. Another more crucial risk factor could be hereditary.

This can be evident in x-ray with articular cartilage destruction, joint space narrowing, cyst formation and juxta-articular osteoporosis, as shown in Fig.2 and 3.

Fig.1

Fig.2

Fig.3

It can manifest with extra-articular presentation like rheumatoid nodule along the forearm and heel (Achilles tendon) as in Fig.4, pleural disease, myocarditis, pericarditis.

Fig.4

Diagnosis is made with the typical presentation of multiple joint pain (particularly small joints), early morning stiffness, rheumatoid factor or anti CCP in the serum and radiographic changes of arthritis.

The focus of treatment should be early diagnosis and to control extent of disease. The streamline of treatment comprises DMARDS (disease modifying anti-rheumatoid drugs) used to combat RA in early stages with significant disease control. Glucocorticoids pave the way for the following line of treatment which rapidly controls the disease process. The recent development is the use of biologic DMARDS like Anakinra, Rituximab and Abatacept, which are infused to maintain multiple inflammatory mediators in patients not responding to the standard treatment protocol.

Patients with significant synovial hypertrophy (inflammation) of large joints like the knee will benefit from Arthroscopic synovectomy, considered the most important inflammatory inducer. In advanced cases of significant joint erosions of the knee, hip and shoulder, total joint replacement is the only available effective treatment that would improve quality of life and render the patients pain-free.

Various other forms of Arthritis do exist, which are namely

Gout (seronegative arthritis) is an alteration in the protein metabolism resulting in either overproduction or reduced excretion of the by-product – uric Acid, which accumulates in small joints initially (great toe) and later may involve other joints. The normal serum uric acid is less than 5.7mg/dl in females and less than 7.7 mg/dl in males. In aggressive cases, uric acid crystal deposition in joints may cause excessive damage. Factors considered causing gout are a high protein diet, alcohol consumption and stress.

Gout can be effectively controlled with appropriate uric acid lowering diet, healthy lifestyle habits and uric acid lowering drugs such as Colchicine, Allopurinol, Febuxostat.

There is a separate entity of arthropathy apart from gout, which is considered seronegative arthritis that shows inflammatory markers in the serum without the presence of RF (rheumatoid factor). These includes:

• Psoriatic arthritis is caused as a secondary to skin disease, and appropriate treatment with steroids and controlling the infectious process will help control or suppress the arthritic process.
• Ankylosing spondylitis is the spinal equivalent of rheumatoid arthritis with cardinal features involving the axial skeleton, especially the sacroiliac joint, asymmetric peripheral joint involvement, usually associated with HLA B 27 gene, pain along with tendon insertion (enthesopathy) with male preponderance.
• Reactive arthritis.
• Juvenile rheumatoid arthritis.

An appropriate diagnosis and early treatment of these conditions shall render a pain-free and healthy life.