NOTES ON PATHOLOGY

Rheumatoid Arthritis  directly activate endothelial cells via increased

production of VCAM1, which increases the adhesion
and accumulation of inflammatory cells
 producing RANKL which in turn activate osteoclasts
causing subchondral bone destruction
Introduction
The inflammatory response leads to Pannus formation

Pannus:
 Is an oedematous thickened hyperplastic
synovium infiltrated by lymphocytes T
and B, plasmocytes, macrophages, and
osteoclasts.
 It will gradually erode bare areas initially,
followed by the articular cartilage.
 Goes on to causes fibrous ankylosis which
eventually ossifies.

Epidemiology
 The overall prevalence is 0.5-1% and the
disease is 2-3 times more common in
women.
Rheumatoid arthritis (RA) is a systemic
autoimmune disease characterized by
 Onset is generally in adulthood, peaking
inflammatory arthritis and extra-articular
in the 4th and 5th decades. The
involvement. RA with symptom duration of
paediatric condition, Juvenile Idiopathic
fewer than six months is defined as early, and
Arthritis (JIA), is discussed separately
when the symptoms have been present for more
than months, it is defined as established.
Risk Factors
There is no laboratory test that is pathognomonic
for rheumatoid arthritis. The treatment of patients Include:
with rheumatoid arthritis requires both
pharmacological and non-pharmacological agents.  Increased prevalence of RA within families
Today, the standard of care is early treatment resulting from the interaction between
with disease modifying anti-rheumatic drugs [ patients genotype and environment.
 Increases risk: Female sex; occupational
dust (silica); air pollution; high sodium
red and iron consumption; low vitamin D
Etiology and Pathology intake and levels; Smoking (seropositive
Etiology is unknown (probably multifactorial). RA); Obesity; Low socioeconomic status
 It is generally considered that  Deceased risk: fish and omega 3 fatty
a genetic predisposition (e.g. HLA-DR B1 which is the acid consumption; moderate alcohol
most common allele of HLA-DR4 involved in intake; healthy diet; oral
rheumatoid arthritis) and an environmental trigger
contraceptive/HRT; statin use.
(e.g. Epstein-Barr virus postulated as a possible
antigen, but not proven) lead to
an autoimmune response that is directed Characteristics/Clinical Presentation
against synovial structures and other organs.  In rheumatoid arthritis, joint complaints
are in the foreground.
Activation and accumulation of CD4 T cells in the  The most common clinical presentation of
synovium start a cascade of inflammatory RA is Polyarthritis of small joints of hands:
responses which result in: proximal interphalangeal (PIP),
 activation of the macrophages and synovial cells and metacarpophalangeal (MCP) joints and
production of cytokines (eg L4 and TNF,) which in wrist. Some patients may present with
turn cause proliferation of the synovial cells and
increase the production of destructive enzymes (eg
monoarticular joint involvement. RA Hand
elastase and collagenase) by macrophages  Commonly joint involvement occurs
 activating B cell lymphocytes to produce insidiously over a period of months,
various antibodies (including rheumatoid factor) however, in some cases, joint
which makes immune complexes that deposit in involvement may occur over weeks or
different tissues and contribute to further injury overnight.
 Other commonly affected joints include
wrist, elbows, shoulders, hips, knees,
 NOTES ON PATHOLOGY

ankles and metatarsophalangeal (MTP)  Significant predictors of functional decline

joints. among persons with RA are slow gait and
 Stiffness in the joints in the morning may a weak grip. [5][6]
last up to several hours, usually greater  Rheumatoid arthritis can affect almost
than an hour. every organ in the body
 The patient may have a "trigger finger"
due to flexor tenosynovitis.  The three most important complaints are
pain, morning stiffness and fatigue.
 Muscular strength, muscular endurance
and aerobic endurance are typically
reduced in patients with rheumatoid
arthritis in comparison with healthy
patients.
 In 80-90% of the patients with rheumatoid
arthritis the cervical spine is involved,
which can lead to instability, caused by
the ligamentous laxity (between the first
and second cervical vertebrae most
commonly) This instability can lead to
pain and neurological symptoms, eg
headache and tingling in the fingers.
 Individuals with RA are 8 times more
likely to have functional disability
compared with adults in the general
 Advanced features of rheumatoid population from the same community.
arthritis, with erosive subluxation most
marked of the MCP joints with ulnar
deviation. Prominent degenerative Staging RA
change is also seen at the ulnar-carpal
articulation. Note also osteopenia
particularly of the MCP regions. On
examination,

 May be swelling, stiffness, deformity, and

tenderness of the PIP, MCP wrist, knee
joints, referred to as synovitis, and there
may be a decreased range of motion.
 Deformity, pain, weakness and restricted
mobility resulting in loss of function.[4]
 Rheumatoid nodules may be present in
20% of patients with rheumatoid arthritis;
these occur over extensor surfaces at
elbows, heels, and toes.
 Late in the course of the disease patient
may present with "boutonniere (flexion at
PIP and extension at DIP), swan neck Disease progression:
(flexion at DIP and extension at PIP)
deformities, subluxation of MCP joints and Stages
ulnar deviation.
 Other features may include the presence 1. No destructive changes on x-rays
of carpal tunnel syndrome, tenosynovitis 2. Presence of x-ray evidence of
and finger deformities. periarticular osteoporosis, subchondral
 Examine the joints on swelling, pain due bone destruction but no joint deformity
to palpation, pain due to movement, 3. X-ray evidence of cartilage and bone
decreased range of motion, deformation destruction in addition to joint deformity
and instability. and periarticular osteoporosis.
 Hallmark symptoms such as symmetrical 4. Presence of bony or fibrous ankylosis
joint swelling and tenderness, morning along with stage 3 features.
stiffness, positive rheumatoid factor (RF), Differential Diagnosis
elevated acute phase reactants, and  Lupus
radiographic evidence of erosive bone  Chronic Lyme disease
loss.  Osteoarthritis
 Septic arthritis
 Psoriatic arthritis
 NOTES ON PATHOLOGY

 Sjogren syndrome Prognosis

 Sarcoidosis Rheumatoid arthritis has no cure and is a
progressive disease. All individuals have multiple
exacerbations and remissions. Close to 50% of
Complications patients with the disease become disabled within
RA has many effects on individuals including 10 years.
mortality, hospitalization, work disability,
increase in medical cost/expenses, decreases  Besides the joint disease, the individuals
of quality of life, and chronic pain. can suffer from many extra joint-related
On average, the chronic RA patient has two or problems which significantly alters the
more comorbid conditions. quality of life. The progression of disease
This is significant because of the comorbidities does vary from individual to individual.
effects on quality of life, functional status,  Rheumatoid arthritis is also associated
prognosis and outcome. Associated with cardiovascular risk factors, infection,
Complications include: respiratory disease and the development
o Infections of malignancies. Patients with rheumatoid
o Chronic anaemia arthritis have a 2-3 times higher risk of
o Gastrointestinal cancers death compared to the general
o Pleural effusions population.
o Osteoporosis
o Heart disease Treatment
o Sicca syndrome  Treatment of rheumatoid arthritis is
o Felty syndrome aimed at improving the symptoms and
slowing disease progression.
o Lymphoma
o Damage to the lung tissue (rheumatoid
 Because the disorder affects many other
lung) organs, it is best managed with an inter-
o Side effects from treatment and professional team. The key is patient
medication. education by nurses, pharmacists, and
o General deconditioning primary care providers. The nurse should
o Neurological complications inform the patient about the signs and
o Ocular complications symptoms of different organ systems and
when to seek medical care. A
Diagnostic Procedures physiotherapist should implement an
1. Lab evaluation of patients with exercise program to recover joint
rheumatoid arthritis consists of obtaining: function. An occupational therapy consult
 Rheumatoid factor (antibody against the can help the patient manage daily living
Fc portion of IgG). About 45% to 75% of activities. The pharmacist should educate
patients with RA test positive for the patient on the types of drugs used to
rheumatoid factor. However, the presence treat rheumatoid arthritis and their
of rheumatoid factor is not diagnostic of potential side effects.
rheumatoid arthritis. It may be present in
connective tissue disease, chronic
infections, and healthy individuals, mostly
in low titers.
 Anti-citrullinated protein antibodies
(ACPA) are found in about 50% of patients
with early arthritis, which subsequently
are diagnosed with RA.
 Acute-phase reactants, erythrocyte
sedimentation rate (ESR) and C-reactive
protein (CRP) may be elevated in the
active phase of arthritis.
2. X-ray of both hands and feet are usually
obtained for the presence of erosions, the
pathognomonic feature of rheumatoid
arthritis (plain radiograph does not show
early changes of the disease).
3. Magnetic resonance imaging (MRI) and
ultrasound of joints detect erosions
earlier than an x-ray. MRI and US are
more sensitive than clinical examination
in identifying synovitis and joint effusion.