UNIVERSITY OF SANTO TOMAS  Continuous pain, progressive deformity & disability

MEDSURG1 – RHEUMATOLOGY
Dr. Fernandez, MD Genetic Factor
 associated with human leukocyte antigen (HLA)-DR4.
Rheumatoid Arthritis  HLA-DR: αβ heterodimer, cell surface receptor
Both α and β chains are anchored in the membrane.
 Systemic inflammatory disease Primary Fx: Present peptide antigens to the immune system
 diarthrodial joints’ synovial membrane leading to the production of antibodies against
the same peptide antigen.
Etiology (Unknown)
 Genetics
 Chronic symmetric synovitis
 Progressive joint destruction, deformity and disability

Nonarticular Manifestations
 Subcutaneous nodule, vasculitis, pericarditis
 Pulmonary nodules, intestinal fibrosis, mononeuritis
multiplex, episcleritis, Sjogren’s, Felty’s syndrome

Factors that Control the Progression, Degree, and Pattern

of Inflammation:
 Genetics
 Oral contraception decreases the risk
 Nulliparity is a risk
 Environmental factors
 Pregnancy is associated with remission Disease Associated Alleles in RA
 Exacerbation in postpartum period  HLA-DRB1*0401
 Symptom onset at menopause  HLA-DRB1 *0404
 HLA-DRB1*0408
Epidemiology
 Prevalence: 0.8% (0.3 to 2.1%) Additional Diseases:
 Increases with age HLA-DRB1*0101/2 Caucasians
 F>M HLA-DRB1*0405 Asians
 Sex difference diminish in the older age group HLA-DRB1*1402 Native American
 Onset >65 y/o: M=F HLA-DRB1*10 Greeks

Pathology Non-genetic Factors

 Smoking
 Microorganisms
 Stress

Diagnosis
Identify presence of an inflammatory synovitis
 Synovial fluid leukocytosis
 Histologic demonstration of chronic synovitis
 Bone erosion by x-ray

RA cannot be diagnosed until the condition is present for at least

several weeks

The American Rheumatism Association 1987 revised

criteria for Classification of Rheumatoid Arthritis
Criterion: (MRS3HRS)
 Morning stiffness > 1 hr
 Rheumatoid nodules
Pathologic Event
 Serum Rheumatoid Factor
 Activation and/or injury of synovial microvascular
 3 or more joints
endothelial cells
 Hand joints (at least 1 area)
 Plasma exudation (edema and joint effusion)  Radiographic changes
 PMNs proliferation  Symmetric arthritis
 Hypertrophy and edema of synovium
 Massive tumor-like proliferation and activation of *Satisfaction of 4-7 of these criteria
CT stroma (pannus) *Criteria 1-4 must be present for at least 6 weeks
 Destruction of periarticular bone and cartilage
 Joint capsule distension or rupture, loss of
subchondral bone (increased osteoclastic activity)
Laboratory  Respiratory
- There is NO laboratory test, histologic or radiographic finding that - Inflammation of cricoarythenoid joint 
conclusively indicates a definitive diagnosis of RA laryngeal pain and dysphonia
- Interstitial lung disease or sterile
Rheumatoid Factor inflammmatory disease
In 85% of RA
Correlate with severe unremitting disease, nodules and  Cardiac
extraarticular lesion - Inflammatory carditis
ESR and C-reactive protein
 Gastrointestinal
Initial Presentation - No specific GI symptom in RA
 Insidiuos over the period of several weeks - Gastritis or PUD secondary to NSAID and
 10% of individuals - Acute Polyarticular Arthritis steroid use

Clinical Features  Renal

1. Morning Stiffness - Related to drug use
 Related to immobilization during sleeping and level of
inflammation  Neurologic
 Prolonged - Myelinopathies related to cervical spine instability
 > 1 hour - Entrapment neuropathies
 Femoral nerve entrapment at the hip joint
2. Active Synovitis  Posterior interosseous at the antecubital fossa
 Usually on superficial joints (knee, wrist, PIPs)  Peroneal at fibular head
 Interdigital nerve at MTP
Manifestations in Specific Joints  Ischemic neuropathies related to vasculitis
1. Cervical spine - Mononeuritis multiplex
- Axonal lesion
 Rare in thoracic and lumbar spine
 Neck stiffness with limited ROM  Hematological
 Tenosynovitis of C1 and C2  C1-C2 instability   Hypochromic-microcytic anemia with low iron
cord compression  Felty’s Syndrome
(splenomegaly, leucopenia and leg ulcers)
2. Shoulders
 Loss of ROM  Frozen Shoulder Syndrome Classification of Progression of RA
Stage 1, Early
3. Elbow  No destructive changes on x-ray
 Flexion deformity  Osteoporosis on x-ray may be present
 Ulnar compression neuropathy
Stage 2, Moderate
4. Hand (Late Stage)  Osteoporosis by x-ray with or without subchondral bone
 Boutonierre Deformity destruction, slight cartilage destruction may be present
 Swan-Neck Deformity  No joint deformities, limited ROM
 MCP Joint Ulnar Deviation  Adjacent muscle atrophy
 Extraarticular soft tissue lesions (nodules, tenosynovitis)
5. Hip
 Symptom is not apparent Stage 3, Severe
 Loss of ROM (+) FABERes  Osteoporosis, cartilage and bone destruction by x-ray
 Joint deformity (subluxation, ulnar deviation, hyperextension
6. Knee withour fibrous or bony ankylosis)
 Baker’s cyst  Extensive muscle atrophy
 rupture (mimics Phlebitis)  Extraarticular lesions

7. Foot and ankle Stage 4, Terminal

 Lateral deviation of the toes  Fibrous ankylosis
 Hallux valgus  Criteria of Stage 3
 Cock-up deformity of MTP/Hammer toe
Course and Prognosis:
Extraarticular Manifestations  Intermittent mild disease with partial/complete periods of
 Skin remission
- Rheumatoid nodule (25-50%) over olecranon, ext. of  Long clinical remission
forearm, Achilles tendon and Ischial area  Progressive disease with either rapid or slow but relentless
 Ocular deterioration
- Keratoconjunctivitis sicca (Sjogren’s)
- Sclertis, episcleritis
Proposed criteria for clinical remission of RA
5 or more of the following for at least 2 consecutive months:
 Duration of morning stiffness not exceeding 15 minutes
 No fatigue
 No joint pain
 No tenderness of pain on motion
 No soft tissue swelling in joints or tendon sheets
 ESR less than 30mm/hr for females or 20mm/hr for males

Poor Prognosis
 Early age of onset
 High RF
 Presence of rheumatoid nodules
 Persistent sustained disease of more than 1 year duration
 HLA-DR4 haplotype

American College of Rheumatology revised Criteria for

Classification of Functional Status in RA
Class I completely able to do ADL

Class II able to do self care and vocational activities but limited

avocational activities

Class III able to do self care but limited vacational and

avocational activities

Class IV limited to ADL

Treament

 Patient education
- Balance between rest and exercise
- Joint protection
- Energy conservation techniques

 Symptomatic medical therapy

- NSAID
- Corticosteroids
- Slow acting Anti-rheumatic Drugs (SAARDs) or Disease
- Modifying Antirheumatic Drugs (DMARDs)
- Anti-cytokine agents
- Immunosupressive therapy

 Surgery

 Rehabiliation
- Pain modalities
- Exercise
- Splinting
- Orthotic or assistive devices

RHEUMATOID ARTHRITIS
Deformities
Ulnar deviation at MCP
Subluxation and radial deviation at the wrist
Swan neck and boutonniere deformity

Ulnar deviation splints

Siris Silver Ring Splints
Allows flexion but blocks hyperextension
Kimmy Garcia
UST – Medsurg1
Rheumatology