Rheumatoid Arthritis

Worldwide rheumatoid arthritis develops in about 1% of the population, regardless of race or country of origin, affecting women 2 to 3 times more often than men. Usually, rheumatoid arthritis first appears between 35 years and 50 years of age, but it may occur at any age. A disorder similar to rheumatoid arthritis can occur in children. The disease is then called juvenile idiopathic arthritis, and the symptoms and prognosis are often somewhat different.

The exact cause of rheumatoid arthritis is not known. It is considered an autoimmune disease. Components of the immune system attack the soft tissue that lines the joints and can also attack connective tissue in many other parts of the body, such as the blood vessels and lungs. Eventually, the cartilage, bone, and ligaments of the joint erode, causing deformity, instability and scarring within the joint. The joints deteriorate at a variable rate. Many factors, including genetic predisposition, may influence the pattern of the disease. Unknown environmental factors (such as viral infections) are thought to play a role.

Symptoms Of Rheumatoid Arthritis

People with rheumatoid arthritis may have a mild course, occasional flare-ups with the long periods of remission (in which the disease is inactive), or a steadily progressive disease, which may be slow or rapid. Rheumatoid arthritis may start suddenly, with many joints becoming inflamed at the same time. More often, it starts subtly, gradually affecting different joints.  Usually, the inflammation is symmetric, with joints on both sides of the body affected about equally. Typically, the small joints in the fingers, toes, hands, feet, wrists, elbows, and ankles become inflamed first. The inflamed joints are usually painful and often stiff, especially just after awakening (such stiffness generally lasts for more than 60 minutes) or after prolonged inactivity. Some people feel tired and weak, especially in the early afternoon. Rheumatoid arthritis may cause a loss of appetite with weight loss and a low-grade fever.

Affected joints are tender, warm, red, and enlarged because of swelling of the soft tissue and sometimes fluid within the joint. Joints can quickly become deformed. Joints may freeze in one position so that they cannot bend or open fully. The fingers may tend to dislocate slightly from their normal position toward the little finger on each hand, causing tendons in the fingers to slip out of place.

Swollen wrists can pinch a nerve and result in numbness or tingling due to carpal tunnel syndrome. Cysts, which may develop behind affected knees, can rupture, causing pain and swelling in the lower legs. Up to 30% of people with rheumatoid arthritis have hard bumps (called rheumatoid nodules) just under the skin, usually near sites of pressure (such as the back of the forearm near the elbow).

Rarely, rheumatoid arthritis causes an inflammation of blood vessels (vasculitis). This condition reduces the blood supply to tissues and may cause nerve damage or leg sores (ulcers). Inflammation of the membranes that cover the lungs (pleura) or of the sac surrounding the heart (pericardium) or inflammation and scarring of the lungs or heart can lead to chest pain or shortness of breath. Some people develop swollen lymph nodes; Sjogren’s syndrome, which consists of dry eyes, mouth, vagina, or a combination; or red, painful eyes caused by inflammation.

Diagnosis Of Rheumatoid Arthritis

In addition to the important characteristic pattern of symptoms, the doctor may use the following to support the diagnosis: laboratory test, an examination of a joint fluid sample obtained with a needle, and even a biopsy (removal of a tissue sample for examination under a microscope) of rheumatoid modules. Characteristic changes in the joints may be seen on x-rays. Magnetic resonance imaging seems to be more sensitive and detects joint abnormalities earlier but is not usually necessary for making the diagnosis.

Blood Test: in 9 to 10 people who have rheumatoid arthritis, the erythrocyte sedimentation rate (ESR – a test that measures the rate at which red blood cells settle to the bottom of a test tube containing blood) is increased, which suggests that active inflammation is present. However, similar increase in the ESR occur in many other disorders. Doctors may monitor the ESR to help determine whether the disease is active.

Many people with rheumatoid arthritis have distinctive antibodies in their blood, such as rheumatoid factor, which is present in 70% of people with rheumatoid arthritis. (Rheumatoid factor also occurs in several other diseases, such as hepatitis and some other infections. Some people even have rheumatoid factor in their blood without any evidence of disease.) Usually, the higher the level of rheumatoid factor in the blood, the more severe the rheumatoid arthritis and the poorer the prognosis. The rheumatoid factor level may decrease when joints are less inflamed,

Anti-citrullinated peptide (anti-CCP) antibiotics are present in 96% of people who have rheumatoid arthritis and are almost always absent in people who do not have rheumatoid arthritis. Doctors are starting by using tests for anti-CCP antibiotics to help diagnose rheumatoid arthritis.

Most people who have mild anemia (an insufficient number of red blood cells). Rarely, the white blood cell count becomes abnormally low. When a person with rheumatoid arthritis has a low white blood count and an enlarged spleen, the disorder is called Felty’s syndrome.

Treatment Of Rheumatoid Arthritis

Treatments include simple, conservative measures in addition to drugs and surgical treatments. Simple measures are meant to help the person’s symptoms and include rest and adequate nutrition. Because disease-modifying antirheumatic drugs (DMARDs) may actually slow progression of the disease as well as relieving symptoms, they are often started soon after the diagnosis of rheumatoid arthritis is made.

Severely inflamed joints should be rested, because using them can aggravate the inflammation. Regular rest periods often help relieve pain, and sometimes a short period of bed rest helps relieve a severe flare-up in its most active, painful stage. Splints can be used to immobilize and rest one or several joints, but some systematic movement of the joints is needed to prevent adjacent muscles from weakening and joints from freezing in place.

A regular, healthy diet is generally appropriate. A diet rich in fish and plant oils but low in red meat can have small beneficial effects on the inflammation. Rarely, people have flare-ups after eating certain foods, and if so, these foods should be avoided. Many diets have been proposed but have not proven helpful. Fad diets should be avoided.

The main categories of drugs used to treat rheumatoid arthritis are the nonsteroidal anti-inflammatory munosuppressive drugs. Never drugs include leflunomide, anakinra (an interleukin -1 receptor antagonist), tumor necrosis factor (TNF)- inhibiting drugs, and other drugs that modify the immune response (immunosuppressive drugs). Generally, stronger drugs have potentially serious side effects that must be looked for during treatment.

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