Rheumatoid Arthritis
Wednesday, April 29th, 2009
Lecture 1
Rheumatoid Arthritis
From the General Practitioner’s Perspective
to the Basic Rheumatologist’s Perspective
Hatem H Eleishi, MD
Professor of Rheumatology, Cairo University
Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital
IN THIS LECTURE
WHAT MANY DOCTORS
KNOW ABOUT
RHEUMATOID ARTHRITIS
WHAT MANY DOCTORS
MIGHT NOT KNOW ABOUT
RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
AS MANY DOCTORS KNOW IT
AN AUTOIMMUNE DISEASE
THAT IS CHARACTERIZED BY:
CLINICALLY:
POLYARTHRITIS
IN TIME, CRIPPLING JOINT DEFORMITIES
LABORATORY:
POSITIVE RF, HIGH ESR
PLAIN RADIOLOGY:
ARTICULAR EROSIONS
MANAGEMENT:
NO REAL TREATMENT;
ONLY NSAIDs, MAY BE STEROIDS
MTX WHICH IS VERY TOXIC
IN SHORT
A CRIPPLING DISASTER THAT MORE OR
LESS HAS NO TREATMENT
RHEUMATOID ARTHRITIS
AS MANY DOCTORS
MIGHT NOT KNOW IT
PRESENTATION
LABS
IMAGING
MANAGEMENT
ABOUT THE PRESENTATION OF
RHEUMATOID ARTHRITIS
TRUE: THE MOST COMMON PRESENTATION IS
A SYMMETRICAL POLYARTHRITIS
IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS
SOMETIMES RATHER SUBTLE,
WE HAVE OTHER PRESENTATIONS TOO;
WE HAVE
THE RELUCTANT RA
THE STUTTERING RA
THE ACHES ALL OVER RA
THE DISGUISED RA
THE PUFFY RA
PRESENTATION 1 OF 5
A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF
PAIN AND SWELLING OF A WRIST OR A SHOULDER OR
AN ANKLE FOR 2 YEARS.
DURATION OF EACH ATTACK: 3-7 DAYS
ATTACK FREE PERIOD: 2-3 MONHTS
THE RELUCTANT RA
OR PALINDROMIC RHEUMATISM
PRESENTATION 2 OF 5
2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY
MONOARTHRITIS OF THE RIGHT WRIST
PLAIN FILM OF HER HANDS: NORMAL
MRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA
EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER
RIGHT WRIST
LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES
STUTTERING
RA
ANY POLYARTHRITIS CAN INITIALLY START AS
A MONOARTHRITIS
RA ON TOP OF OA
OR DISGUISED RA
FEMALE; 48Y-OLD
OA KNEES / HANDS
LATELY PAIN
NOCTURNAL PAINS
REC EFFUSIONS
RA
RA
PLAINS: OA
ESR 50
RF +VE
SYNOVIONALYSIS: INFLAMMATORY SF
PRESENTATION
3 OF 5
PRESENTATION 4 OF 5
Mona, a 32-year old female, presented with diffuse
aches all over of 3 months’ duration. She had a MS
of 10-60 minutes and nocturnal pain sometimes.
She was afraid she might have cancer or
rheumatoid arthritis but had been reassured
by her family doctor that she didn’t have
cancer and that her RF test was negative.
Examination
revealed a very anxious patient with inconsistent
tenderness over several small joints of the hands but also over the trunk
as well as the flesh of the forearms and legs.
Investigations:
ESR 21
CBC, liver, kidney, electrolytes: normal
RF; ANA: negative
Hepatitis serology: negative
A plain film of the hands and feet were normal
A Tc99 bone scan was done
DIFFUSE ACHES ALL OVER RA
OR FIBROMYALGIC RA
Early rheumatoid arthritis can sometimes be
a vague diagnosis
Bone scan helps
to settle the diagnosis
in such situations
PRESENTATION 5 OF 5
Abu-Ismail, a 59-year old male, presented with gradual onset of pain and
swelling of his hands with NP and MS of 4 hours
Examination: diffuse swelling (puffinness) of the dorsum of both hands;
tenderness of the MCPs, and wrists
LABS: ESR 70; Hb 11gm%; RF: Negative
RS3PE
REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS
WITH PITTING EDEMA
OR PUFFY
RA
THE RELUCTANT RA
THE STUTTERING RA
THE ACHES ALL OVER RA
THE SNEEKY RA
THE PUFFY RA
RHEUMATOID ARTHRITIS
AS MANY DOCTORS
MIGHT NOT KNOW IT
PRESENTATION
LABS
IMAGING
MANAGEMENT
ABOUT
THE LABORATORY INVESTIGATIONS
IN RHEMATOID ARTHRITIS
POSITIVE RHEUMATOID FACTOR
“THE RHEUMATOID CETRTIFICATE”
THERE ARE CAUSES FOR A POSITIVE RF
OTHER THAN RA
SO YOU CANNOT RELY SOLELY ON A
POSITIVE RF TO DIAGNOSE RA
NEGATIVE RHEUMATOID FACTOR
RHEUMATOID FACTOR IS POSITIVE IN
ONLY 70% OF PATIENTS AND NEGATIVE
IN 30%
SO A NEGATIVE RF DOESN’T RELIABLY
EXCLUDE RA
ESR
ESR IS NOT INVARIABLY ELEVATED
IN RA
ABOUT THE IMAGING OF
RHEUMATOID ARTHRITIS
NOT EVERY RHEUMATOID DISEASE IS
NECESSARILY EROSIVE
BEFORE LOOKING FOR
EROSIONS,
LOOK FIRST FOR:
JAO
JSN
IN EARLY RA, PLAIN FILMS MAY BE NORMAL
ANYWAY
OTHER IMAGING MODALITIES MAY THEN BE
NEEDED TO CONFIRM THE DIAGNOSIS
What is the most important thing that is needed to make the diagnosis of RA?
A good lab
An imaging center
A chair
A screening questionnaire for the population
Knowing the family history of your patient
Two doctors rather than one
HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO
THE CORRECT DIAGNOSIS
THERE ARE 3 TYPES OF HISTORY THAT COULD BE
TAKEN FROM A PATIENT:
THE JOURNALIST’S HISTORY
THE POLICE OFFICER’S HISTORY
THE GOOD DOCTOR’S HISTORY
GOOD DOCTORS
DO NOT
DIAGNOSE DISEASES
THEY JUST LEAVE DISEASES
DIAGNOSE THEMSELVES
‫األمراض مثل البشر ‪ ،‬لكل مرض‬
‫مالمحه المميزة و طبائعه الخاصة‬
‫التي يدرسها الطبيب ثم تزداد و‬
‫تصقل معرفته بها بالممارسة و‬
‫البحث و اإلطالع المستمر‪.‬‬
‫يتعرف الطبيب على هذه المالمح المميزة في أثناء الحوار مع المريض‬
‫وعلى هذا فإن أهم خطوة لتشخيص المرض هي‪:‬‬
‫اإلستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب‬
‫ماذا يحدث باإلستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب؟‬
‫يقع المريض في حفرة‪........‬‬
‫ماذا يفعل‬
‫الطبيب في‬
‫هذه الحالة؟‬
‫يسيبه يقع‬
‫لوحده‪،‬‬
‫ما يزقوش‬
ABOUT THE MANAGEMENT OF
RHEUMATOID ARTHRITIS
MANAGEMENT OF RA COMPRISES:
PATIENT EDUCATION AND INSTRUCTIONS
MEDICAL TREATMENT
REHABILITATION
SURGICAL TREATMENT SOMETIMES
DON’T UNDERESTIMATE THE POWER OF
TALKING TO YOUR PATIENT
PATIENT EDUCATION
MEDICAL TREATMENT
REHABILITATION
NSAIDs
AND
PHYSIOTHERAPY
Hydroxychloroquine, sulfasalazine, gold
Methotrexate, lefulonamide
Biological Agents
Aim of medical treatment:
Induction and maintenance of remission
Corticosteroids are not part of the
medical treatment of RA except in very
selected situations as:
Severe
systemic
illness
Bridge therapy
Conclusions
THERE IS MUCH MORE ABOUT
RHEUMATOID
ARTHRITIS
THAN
JUST:
A CRIPPLING JOINT DISEASE
WITH A POSITIVE RF
AND NO TREATMENT
PRESENTATION
A SYMMETRIC POLYARTHRITIS IS THE
COMMONEST PRESENTATION,
BUT
THERE ARE OTHER NOT UNCOMMON
PRESENTATIONS FOR RHEUMATOID
ARTHRITIS AS WELL
PRESENTATION
THE MOST IMPORTANT STEP TOWARDS
A DIAGNOSIS OF RA IS
A GOOD HISTORY
TAKEN BY
A GOOD DOCTOR
INVESTIGATIONS
A POSITIVE RF DOESN’T
NECESSARILY MEAN RA
AND
A NEGATIVE RF DOESN’T
NECESSARILY MEAN NO RA
INVESTIGATIONS
PLAIN FILMS IN EARLY RA
MAY BE NORMAL
MANAGEMENT
DOCTORS ARE MORE THAN JUST
TABLETS
MANAGEMENT
A MOST INDISPENSIBLE STEP IN THE
MANGEMENT OF PATIENTS WITH RA IS
PATIENT EDUCATION
MANAGEMENT
CORTICOSTEROIDS HAVE NO
PLACE IN THE TREATMENT OF RA
EXCEPT IN
VERY SPECIAL SITUATIONS
MANAGEMENT
VARIOUS IMMUNOMODULATORS
AND IMMUNOSUPPRESSIVES AND
BIOLOGICAL AGENTS ARE
AVAILIABLE FOR THE INDUCTION
AND MAINTENANCE OF
REMISSION IN PATIENTS WITH
RHEUMATOID ARTHRITIS
Thank you