Signs And Symptoms Of Rheumatoid Arthritis

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Contents 1 Signs And Symptoms Of Rheumatoid Arthritis 2 The RF titer (=rheumatoid factor titer) 3 Sjögren's syndrome 4 Felty syndrome

[edit] Signs And Symptoms Of Rheumatoid Arthritis

The onset of rheumatoid arthritis(RA) is mostly very gradual, but sometimes it might start with an acute episode. It tends to affect the small joints in a diffuse manner, called polyarthritis, as many joints of the hands and of the upper neck are simultaneously affected. In the beginning it affects only perhaps three or four of the "knuckles"of the hands.

These are called metacarpophalangeal joints or "MCP joints" for short. There will be pain, swelling, heat, some redness of the overlying skin and loss of range of motion of the affected small joints. The joints have effusions (fluid build-up) and the synovial membranes get inflammed, a condition termed"synovitis". This process leads to eventual scarring and joint stiffness.

Unfortunately the inflammatory process does not stop at the joint level at all, but it also involves the tendons that travel across the joints in the hands and the support ligaments. Loss of these support structures leads to the grotesque deformities with ulnar deviation of the MCP joints. Tendons thicken and show nodules and can even rupture due to a softening up of the structure as a result of the inflammatory process (Ref. 1 and 2).

[edit] The RF titer (=rheumatoid factor titer) It is poorly understood why the immune system is changed in rheumatoid arthritis patients, but this seems to be the underlying pathophysiological process that is behind all of these symptoms. We do know that the immune system in rheumatoid arthritis patients is altered and produces an abnormal antibody to altered immunoglobulins. This is called the rheumatoid factor (RF) or rheumatoid antibody. If it is low, the disease process is not yet systemic, if it is high, the disease is more aggressive and systemic spread into all body joints is more likely. This blood test then together with the erythrocyte sedimentation rate(=ESR) is a useful test to help diagnose and monitor the progress of the treatment of rheumatoid arthritis. This antibody in RA is directed at altered proteins in the synovial membrane of joints, tendon sheaths and in a few more serious cases in other areas of the connective tissue including arterial walls. This distinguishes RA from other connective tissue diseases such as Sjögren's syndrome where the autoantibody is directed more against the salivary and lacrimal glands resulting in a dry mouth and in dry eyes. There is ample evidence in the immunological literature that the key to understanding RA and other connective tissues diseases is found in the altered immune response (T helper cells, plasma cells, macrophages, autoantibodies etc.). This leads to joint, cartilage and tendon destruction.

The following summarizes various other symptoms and signs of RA (modif. from Ref. 1 and 2):

In the spine the upper end of the cervical spine is often affected with subluxations of the joints between the first and second vertebral bodies(atlantoaxial subluxation ).There is a danger of spinal stenosis and/or spinal cord compression.

Rheumatoid nodules happen in about 20% of patients with RA. They are hardened fibrotic lumps in the skin at the outside of the extensor surface where pressure occurs from leaning on them, as well as the Achilles tendons, where shoes exert pressure onto the skin.

Vascular damage from immune complexes that are deposited in the vascular walls.

A variety of different clinical signs are associated with this: skin ulcers, occlusion of vessels going to fingers or toes with a threat of loss of these. The nutritional vessels of nerves can be affected and a painful neuritis of a nerve can develop. The minifiltration system of the kidneys can be damaged (glomerular vessel infarcts), which makes the kidneys much more prone to toxicity of drugs that are used to treat RA. In the final stage a rare condition, called amyloidosis can lead to even more kidney damage.

[edit] Sjögren's syndrome

(often spelled as "Sjogren's" syndrome)

In these patients there is a drying up of salivary gland secretions and lacrimal gland secretions leading to a dry mouth and dry eyes. It is important that these patients use artificial tears to prevent serious corneal damage and blindness. Dryness can also develop in the skin, the mucous membranes of the nose, throat, upper airways and bronchial tubes and the genitals.

This leads to more frequent bronchitis infections and pneumonias. The immune system is so seriously altered that Sjögren's patients have a risk of about 40-fold over the normal risk to develop lymphomas. Pancreatitis is common as this too is a glandular organ.

Joint involvement is similar to RA, but the joint swelling and progression of symptoms is much more benign and self-limiting. Treatment is conservative and concentrates on symptomatic control of the symptoms. Care must be taken that the physician does not harm the patient by overzealous therapies. For instance one has to be careful not to overuse corticosteroids and one should not use methotrexate for Sjögren's syndrome patients as their immune system is already compromised and these therapies could trigger the development of a lymphoma.

Eye involvement : Episcleritis is an irritation of the conjunctiva with reddening, irritation, light sensitivity, increased tear flow and tenderness. It is self limiting and can also present with some rheumatoid nodules. It does not threaten the vision.

Scleritis: This condition affects the deeper layers of the sclera (the white of the eye). Pain with this condition is so severe that it can interfere with sleep and appetite. There is sensitivity to light, a nodular redness, which in time turns into scarring and thinning of the sclera, which gives it a bluish-grey appearance. This is potentially a threat to vision as the scarring can permanently damage the eye by spontaneous rupture of the eye.

[edit] Felty syndrome

This syndrome consisits of a combination of RA , enlarged spleen and bone marrow suppression (with low white blood cell counts). It leads to serious infections because of a weakness in the immune system and vasculitis, which is associated with leg ulcers and nerve damage (mononeuritis). Other findings are low platelets associated with prolonged bleeding and anemia. The lymph glands can be enlarged and this needs to be separated from lymphomas and leukemias.

Neurological problems: Nerve entrapments are common such as carpal tunnel syndrome and ulnar neuropathy affecting sensitivity and strength in the hands and wrists, tarsal tunnel syndrome in the ankles/feet and other more rare signs. Nerve root compressions are also found, more commonly in the cervical spine, but sometimes also in the lumbar spine from subluxations and compression fractures of end stage RA of facet joints and osteoporosis. There is a great danger to the spinal cord when the bony spinal support structure has been eroded.

Immunological abnormalities: There are a number of immunological abnormalities that are found in patients with RA. The most well known is the already mentioned rheumatoid facor (RF), which is an abnormal antibody directed against the altered immunogloblulins IgG and IgM.

The higher the titer, the more likely that there is an antibody/antigen reaction and immune complexes form. These in turn will cause vasculitis, glomerulonephritis (a kidney disease) and neuropathies, as was earlier indicated. About 80% of patients have seropositive RA, where the RF is present. On the other hand 20% have seronegative arthritis and they have all the clinical signs of RA. Other parts of the immune system are also affected: The synovial membranes are infiltrated by T helper lymphocytes that help the plasma cells to produce RF. Macrophages that process the synovial membrane antigen are also present in the joint effusions of RA patients. The immune complexes lead to release of prostaglandins and enzymes in the joints that destroy cartilage, ligaments and tendons.

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