Artritis Reumatoide
Artritis Reumatoide
Artritis Reumatoide
Please cite this article in press as: Gulati M, et al., Clinical features of rheumatoid arthritis, Medicine (2018), https://doi.org/10.1016/
j.mpmed.2018.01.008
RHEUMATOID ARTHRITIS
Ocular Vascular
• Keratoconjunctivitis sicca • Rheumatoid vasculitis
• Episcleritis • Raynaud’s
• Scleritis • Atherosclerosis
• Scleromalacia perforans
Cardiac
Pulmonary • Coronary artery disease
• Parenchymal lung disease • Pericarditis
• Pleural disease
• Airways disease
• Complications of DMARDs Renal
• Tubulo-interstitial nephritis
• AA amyloid
Skin • Membranous
• Rheumatoid nodules glomerulonephritis
• Vascular lesions
Musculoskeletal
Gastrointestinal • Joint
• Oesophagitis, gastritis and • Tendon
peptic ulcer disease • Bursa
• Hepatotoxicity from DMARDs • Muscle
• Bone
Neurological
• Entrapment neuropathy Haematological
• Cervical myelopathy • Anaemia
• Peripheral neuropathy • Thrombocytosis
• Mononeuritis multiplex • Felty’s syndrome
Figure 1
Flexor tenosynovitis can result in pain and ‘triggering’ of the MTPJs are at risk of deformity because of synovitis and high
fingers. Tenderness, thickening and nodule formation are load-bearing. Hallux valgus can develop, with subluxation of the
palpable along the tendon. other phalanges and claw toe formation resulting from flexor
Established RA changes at the MCPJs cause volar subluxation tendon involvement. This alters biomechanics such that the
and ulnar deviation. These are a consequence of damage to the second and third MTPJs predominantly bear the load, with
volar plate, tendons and supporting ligaments caused by syno- resultant pain, underlying callosities and deformity.
vial inflammation. The posterior tibialis tendon and the subtalar and talona-
Ulnar deviation at the MCPJs is associated with radial devia- vicular joints are frequently involved in RA, causing pain, ero-
tion at the wrist. Dorsal subluxation of the ulna results in a sions and subtalar dislocation with loss of the arch of the foot.
‘piano key’ movement allowing the ulna to be depressed. This Active synovitis at the knee results in pain and effusion.
bony movement can cause damage to extensor tendons and Secondary degenerative changes are common. Posterior knee
rupture. pain can result from an enlarged Baker’s cyst.
Synovitis at the wrist and deformity can result in entrapment The hip is less commonly involved in RA; synovitis is difficult
neuropathies e carpal tunnel syndrome and, less commonly, to elicit because of the deep-seated location.
ulnar neuropathy. Cervical spine e involvement of the cervical spine is less
Tenderness, synovitis, effusion and flexion deformity may be common with modern therapies, and is usually seen in in-
seen at the elbow. dividuals with advanced disease. Patients report neck and oc-
Swelling at the shoulder is difficult to elicit. RA commonly cipital pain; neurological features can be present as a result of
involves the shoulder joint, causing rotator cuff tendinopathy, compression of the nerve roots or spinal cord.
tendon rupture, synovitis and bursitis. Patients can report pain, The atlas (C1) has a strong transverse ligament that maintains
stiffness and limited range of movement. the odontoid process (also known as the dens or peg) of the axis
Lower limbs e the feet should be inspected for swelling and (C2) against the posterior surface of the atlas (Figure 2). There is
deformity, and in particular for loss of the longitudinal arch. The a synovial articulation between the transverse ligament and the
Please cite this article in press as: Gulati M, et al., Clinical features of rheumatoid arthritis, Medicine (2018), https://doi.org/10.1016/
j.mpmed.2018.01.008
RHEUMATOID ARTHRITIS
Atlas (C1)
Odontoid peg
Transverse
ligament
Spinal cord
Anterior Anterior
Figure 2 A diagrammatic representation of atlanto-axial subluxation viewed axially, caused by rupture of the transverse ligament secondary to
localized pannus formation, and migration of the atlas towards the cervical spinal cord, resulting in cervical myelopathy. Left: healthy state; right,
atlanto-axial subluxation.
posterior aspect of the odontoid process. Synovitis at this site can Vascular:
result in odontoid erosion, instability of the transverse ligament Atherosclerosis e this is the most common vascular compli-
and rupture, placing the spinal cord at risk. The extended neck cation of RA. The risk of atherosclerosis correlates with the de-
position increases the risk of subluxation. Rarely, vertical gree of inflammation; reducing inflammation may reduce
movement of the odontoid process into the foramen magnum cardiovascular risk.
occurs e this can be fatal. Rheumatoid vasculitis e rheumatoid vasculitis typically
Other joints e temporomandibular joint (synovitis can presents as petechiae, purpura or ulceration caused by inflam-
restrict mouth opening, and in children can result in micro- mation of the larger arterioles or arteries. This is a relatively rare
gnathia). Involvement of the cricoarytenoid joint causes a change complication that can also be associated with peripheral neu-
in voice. ropathy or involvement of the internal organs. When present,
vasculitis often indicates severe disease and requires
Tendons: trigger finger is seen in hand flexor tenosynovitis, immunosuppression.
where the pathology results from a thickened tendon and ste- Raynaud’s e Raynaud’s phenomenon rarely affects patients
nosis of the tendon sheath. Clinically, a thickened tendon with a with RA. Pathophysiology and management are similar to those
painful nodule is palpable. of patients with Raynaud’s secondary to other connective tissue
Extensor tenosynovitis is evident as swelling on the dorsum of diseases.
the hand, accentuated by asking the patient to extend their fin-
gers. Rupture of the extensor tendons is more common than that Neurological: entrapment neuropathy and cervical myelopathy
of the flexor tendons. were discussed above. RA can cause a length-dependent pe-
ripheral neuropathy in a glove-and-stocking distribution, typi-
Bursae: bursitis can develop at a number of sites e olecranon, cally presenting as tingling and paraesthesia. Less common is
subacromial subdeltoid and trochanteric bursitis. mononeuritis multiplex, presenting as a sensorimotor
neuropathy.
Muscles: sarcopenia is common and results from deconditioning
caused by pain, corticosteroid use and neuropathy. Atrophy of Haematological:
the intrinsic muscles of the hand can be marked in advanced RA. Anaemia e the most common haematological manifestation
of RA is anaemia of chronic disease, manifesting as normocytic
Bones: although active synovitis can cause erosions at articular anaemia. This correlates with disease activity and acute-phase
sites, RA is associated with low bone density. This occurs as a response. Patients can develop iron deficiency anaemia second-
result of corticosteroid use and immobility. ary to gastrointestinal blood loss from chronic non-steroidal anti-
inflammatory drug (NSAID) and glucocorticoid use. Vitamin B12
Extra-articular manifestations of rheumatoid arthritis and folate deficiency can be a cause of anaemia in RA, especially
Skin: rheumatoid nodules are the most common skin manifes- with methotrexate.
tation of RA. These are typically observed in seropositive patients Thrombocytosis e this is part of the acute-phase response.
and located subcutaneously at pressure areas (e.g. olecranon, Felty’s syndrome e this is a triad of RA, splenomegaly and
occiput, Achilles). They are firm and rubbery without being neutropenia. Thrombocytopenia can be observed. This may not
tender. There can be a discrepancy between the severity of correlate with the articular disease but is managed by optimizing
articular inflammation and the degree of rheumatoid nodulosis. disease-modifying therapy.2
Other skin manifestations of RA relate to vascular aetiology,
for example vasculitis, purpura and ulceration, including pyo- Pulmonary disease: in patients with RA, pulmonary disease can
derma gangrenosum. be caused by the disease or by infections in an
Please cite this article in press as: Gulati M, et al., Clinical features of rheumatoid arthritis, Medicine (2018), https://doi.org/10.1016/
j.mpmed.2018.01.008
RHEUMATOID ARTHRITIS
immunocompromised host, or be an adverse consequence of NSAID use or nephropathy secondary to DMARD therapy, typi-
immune-modulatory therapy.3 cally with older generation drugs such as penicillamine and gold
Parenchymal lung disease e this includes RA interstitial lung (which are now rarely used), and caused by chronic inflamma-
disease (RA-ILD) and, less commonly, pulmonary rheumatoid tion. This presents with proteinuria and can progress to
nodulosis. Although RA-ILD is considered a late complication, it nephrotic syndrome. This complication is uncommon with
is increasingly recognized that a proportion of asymptomatic RA modern therapies that allow tighter control of disease activity.
patients have undiagnosed RA-ILD early in the disease. Risk
factors for RA-ILD include male sex, older age, smoking history Gastrointestinal manifestations: RA does not directly affect the
and seropositivity. gastrointestinal tract. Chronic NSAID and corticosteroid use are
The most common high-resolution computed tomography associated with oesophagitis, gastritis and peptic ulcer disease.
(HRCT) pattern is usual interstitial pneumonitis, typified by Hepatic toxicity may be seen with DMARD therapy.
bilateral subpleural basal disease with honeycombing. The next
most common pattern is non-specific interstitial pneumonitis, Ocular manifestations:
which is typically associated with other connective tissue dis- Keratoconjunctivitis sicca e this can present on its own or in
eases and is characterized by ground-glass changes and mosai- the context of secondary Sjo €gren’s syndrome. The severity of
cism. Some patients develop an organizing pneumonia with symptoms correlates with the patient’s age and the duration of
patches of consolidation.4 RA, but not with the severity of peripheral arthritis.5
Pulmonary rheumatoid nodulosis is less common and has a Episcleritis e this is inflammation of the superficial layer of
wide differential diagnosis that includes infection and malig- the sclera, presenting as acute-onset red injection in one or both
nancy. In the context of pneumoconiosis, calcified pulmonary eyes, causing pain and photophobia.
nodules are known as Caplan’s lungs. Scleritis e this is an ocular emergency. Anterior scleritis is
Pleural disease e pleuritis and pleurisy can be associated characterized by a red eye that sometimes has a characteristic
with exudative pleural effusion. Rarely, recurrent pleuritis can violet hue. Pain is often described as a boring pain. Scleral
lead to pleural fibrosis. In some cases, bronchopleural fistula and dilatation can be sight-threatening. Posterior scleritis presents
pneumothorax can result from a ruptured subpleural rheumatoid with severe retro-orbital pain. Fundoscopy may reveal retinal
nodule. vasculitis, optic nerve oedema and retinal detachment. Scleritis is
Airways disease e RA can involve small and large airways. often associated with long-standing RA and is more common in
Bronchiectasis from recurrent infection can be identified on patients with other extra-articular manifestations. If suspected, it
HRCT. Rarely, patients can present with smaller airways disease requires urgent review by an ophthalmologist.
such as bronchiolitis and bronchiolitis obliterans that require Scleromalacia perforans e this is a very rare complication
prompt immunosuppression. that causes thinning of the sclera with a darkish blue tinge from
Complications of disease-modifying antirheumatic drugs the appearance of the underlying black choroid layer. Scle-
(DMARDs) e a common adverse complication of synthetic and romalacia is a late presentation with a relatively poor
biologic DMARD treatment is upper and lower respiratory tract prognosis. A
infections. Opportunistic infections can occur in this immuno-
compromised population. Drugs including methotrexate and
KEY REFERENCES
tumour necrosis factor inhibitors can cause interstitial pneumo-
1 Arthritis Research UK. State of musculoskeletal health. 2017,
nitis. Management involves discontinuation of the drug, supportive
http://www.arthritisresearchuk.org/arthritis-information/data-and-
measures and, in severe cases, intravenous corticosteroids.
statistics/state-of-musculoskeletal-health.aspx (accessed 3 Sep
2017).
Cardiac disease:
2 Rozin AP, Hoffman R, Hayek T, Balbir-Gurman A. Felty’s syndrome
Coronary artery disease e atherosclerosis in RA has been
without rheumatoid arthritis? Clin Rheumatol 2013; 32: 70e4.
discussed above.
3 European League Against Rheumatism. EULAR online course on
Pericarditis e as with pleural disease, the pericardium can
rheumatic disease. https://www.eular.org/edu_online_course.cfm
become inflamed, resulting in chest pain and rarely pericardial
(accessed 10 Sep 2017).
effusion. Myocardial and endocardial inflammation can be pre-
4 Kim EJ, Collard HR, King TE. Rheumatoid arthritis-associated
sent. Severity of pericardial involvement often correlates with
interstitial lung disease: the relevance of histopathologic and
articular disease and is controlled with DMARD therapy.
radiographic pattern. Chest 2009; 136: 1397e405.
5 Almaliotis D, Zakalka M, Gerofotis A, et al. Ocular manifestations in
Renal disease: the kidney is rarely affected directly by RA.
rheumatoid arthritis. Open J Ophthalmol 2016; 6: 170.
Tubulo-interstitial nephritis can occur secondary to chronic
Please cite this article in press as: Gulati M, et al., Clinical features of rheumatoid arthritis, Medicine (2018), https://doi.org/10.1016/
j.mpmed.2018.01.008
RHEUMATOID ARTHRITIS
TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.
Please cite this article in press as: Gulati M, et al., Clinical features of rheumatoid arthritis, Medicine (2018), https://doi.org/10.1016/
j.mpmed.2018.01.008