Rheumatoid Arthritis
Presentation
Sir, this patient has Rheumatoid arthritis affecting the hands as evidenced by
Presence of symmetrical deforming polyarthropathy
PIPJ/MCPJ
Swan neck, Boutonniere’s, Z-thumb, ulna deviation
Subluxation (MCPJ, dorsal subluxation of the ulna at the carpal joint)
Active arthritis/quiescent
Intrinsic muscle wasting
CTS
Dropped fingers from tendon rupture
Synovial thickening
Vasculitic lesions, nail-fold infarcts
Palmar erythema
No nail changes and skin lesions of Psoriasis
SLE skin changes
Elbows for Rh nodules
Function
Preserved vs impaired
Coarse and fine functions
Treatment
Steroid – atrophied skin, bruisability
Surgical intervention – CTS decompression, tendon release
Requests
Other joint involvement (MTPJ, knees)
Extra articular features of RA
Questions
What are the extra-articular features of RA?
 Eye
o Conjunctiva – Keratoconjunctivitis sicca, pallor
o Sclera – episcleritis, scleritis, scleromalacia perforans
o Lens – Cataracts from chronic steroid usage
o Retina – vasculitis, drug induced (Gold, Hydroxychloroquine)
o Extra-ocular muscles – mononeuritis multiplex, myasthenia sec to
penicillamine



Respiratory
o Upper airways – Cricoarytenoid
o Pleura – pleurisy, effusions
o Airway – BOOP
o Parenchyma – Pulmonary fibrosis, pneumonitis, PHT ( RA or MTX)
o Caplan’s, Nodules
Neurological
o Peripheral neuropathy
o Mononeuritis multiplex
o Nerve entrapment
o Cx atlanto-axial subluxation +/- Cx myelopathy
o Muscle atrophy, proximal myopathy sec to steroids, penicillamine induced
myasthenia
Abdomen
o Splenomegaly in Felty’s syndrome
What are the causes of anaemia in RA?
 Fe deficiency – GI bleed from NSAIDS
 Megaloblastic anaemia – Pernicious anaemia
 Anaemia of Chronic disease
 Hypersplenism from Felty’s Syndrome
 Aplasia – Gold, Penicillamine
What are the poor prognostic indicators?
 Insidious onset and high activity at onset
 Rh nodules or early erosions within 1 year
 Extra-articular features
 Persistent activity after 1 year – Active arthritis, ESR
 High levels of Rh factor and Anti CCP Ab (anti cyclic citrullinated peptide Ab)
What are the criteria for Dx RA (American college of Rheumatology)?
Any 4 of the following:
 Morning Stiffness for >1 hr duration for > 6 weeks
 Arthritis of 3 or more joints for > 6 weeks
 Arthritis of wrists, MTCP, PIPJ
 Symmetric
 Rh nodules
 Rh factor
 Radiographic changes typical changes including erosions or unequivocal
decalcification
How would you investigate this patient?
 Blood Ix – Rh factor, anti-CCP, ESR, CRP
 X-rays of the joints – erosions and periarticular osteopenia
How would you manage this patient?
 Education and counselling
 Non-pharmacological
o OT, PT
 Pharmacological which will depend on the severity
o Analgesia – NASIDS
o DMARDS
 Methotrexate (Check FBC and LFT)
 Sulphasalazine
 Hydroxychloroquine
 Low dose prednisolone
 Newer agents
 Leflunomide
 Tacrolimus
 Cyclosporine A
 Rapamune (sirolimus)
o Immunomodulators (biologics)
 Anti TNF – Etarnacept (FDA approved), infliximab, humira
 Beware of TB and atypical pneumonia resulting from their
use
 Anti CD20 – Rituximab
 Surgical
What is Z thumb deformity?
 Deformity that occurs in RA hands
 With hyperextension of the first IPJ and fixed flexion and subluxation of the first
MCPJ
 Resulting squaring appearance of the hands
What is Boutonnière’s deformity?
 Hyperflexion of the PIPJ and hyperextension of the DIPJ
 Due to rupture of the central slip of the extensor tendon over the PIPJ with
imbalance of the flexion and extension forces of the finger
What is swan neck deformity of the fingers?
 Hyperextension of the PIPJ and hyperflexion of the DIPJ
 Due to synovitis of the flexor tendons leading to flexion at the MCPJ with
constant effort to extend the finger; leading to stretching of the collateral
ligaments and the volar plate of the PIPJ; intrinsic muscle balance leads to swan
neck deformity
What are the differential diagnoses for deforming polyarthropathy of the hands?
 Rheumatoid arthritis
 Psoriatic arthritis of the RA type

Jaccoud’s arthropathy which is ulna deviation with subluxation of the 2nd to 5th
fingers at the MCPJ which is voluntarily correctable; initially described in
patient’s with Rh fever but now used synonymously with SLE deforming
arthropathy