Rheumatoid arthritis
Background
- Rheumatoid arthritis is an autoimmune disease. It is an erosive polyarthritis that causes auto-antibodies direct against an individual's own joints and joint spaces.
Clinical Features
Rheumatoid nodules on the extensor surfaces can develop in poorly controlled rheumatoid arthritis
Multiple swan neck deformities from poorly controlled rheumatoid arthritis
- Morning stiffness
- Polyarthritis of MCP and PIP joints
- Does NOT involve DIP joints
- Wrists, elbows, shoulders, ankles, knees also commonly involved
- Ulnar deviation at MTP joints
- Swan neck deformity
- Rheumatoid nodules
- Most patients initially diagnosed in the early 50s
- Common associated conditions in severe cases: pleuritis, interstitial lung disease, pericarditis, inflammatory eye disease
Differential Diagnosis
Polyarthritis
Algorithm for Polyarticular arthralgia
- Fibromyalgia
- Juvenile idiopathic arthritis
- Lyme disease
- Osteoarthritis
- Psoriatic arthritis
- Reactive poststreptococcal arthritis
- Rheumatoid arthritis
- Rheumatic fever
- Serum sickness
- Systemic lupus erythematosus
- Serum sickness–like reactions
- Viral arthritis
Migratory Arthritis
- Gonococcal arthritis
- Lyme disease
- Rheumatic fever
- Systemic lupus erythematosus
- Viral arthritis
Evaluation
- Xray affected joints for erosions
- Rheumatoid factor (positive in 60% to 70% of patients)
- Anti-cyclic citrullinated peptide (CCP) antibodies (positive in about 70% of patients)
- ANA
- Consider arthrocentesis
- WBC count typically 1,500-20,000
Management
- NSAIDs
- Symptomatic relief without slowing underlying disease
- Glucocorticoids
- Consider intraarticular injection if a single joint is inflammed
- Systemic steroids reserved for moderate-severe flairs
- Opioids have a limited role
- Disease-modifying antirheumatic drug (DMARD)
- Can be started by primary care provider or rheumatologist after ER visit
Disposition
- Discharge with referral to PCP or rheumatology
See Also
References
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