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Rheumatoid Arthritis Wednesday , April 29 th , 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

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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. SolimanFakeeh Hospital

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IN THIS LECTURE

WHAT MANY DOCTORS

KNOW ABOUT

RHEUMATOID ARTHRITIS

WHAT MANY DOCTORS

MIGHT NOT KNOW ABOUT

RHEUMATOID ARTHRITIS

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RHEUMATOID ARTHRITIS

AS MANY DOCTORS KNOW IT

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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

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IN SHORT

A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT

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RHEUMATOID ARTHRITIS

AS MANY DOCTORS

MIGHT NOT KNOW IT

PRESENTATION

LABS

IMAGING

MANAGEMENT

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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;

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WE HAVE

THE RELUCTANT RA

THE STUTTERING RA

THE ACHES ALL OVER RA

THE DISGUISED RA

THE PUFFY RA

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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

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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

S T U T T E R I N G RA

ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS

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RA

RA

RA ON TOP OF OA

OR DISGUISED RA

FEMALE; 48Y-OLD

OA KNEES / HANDS

LATELY PAIN

NOCTURNAL PAINS

REC EFFUSIONS

PLAINS: OA

ESR 50

RF +VE

SYNOVIONALYSIS: INFLAMMATORY SF

PRESENTATION

3 OF 5

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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.

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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

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A Tc99 bone scan was done

DIFFUSE ACHES ALL OVER RA

OR FIBROMYALGIC RA

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Early rheumatoid arthritis can sometimes be

a vague diagnosis

Bone scan helps

to settle the diagnosis

in such situations

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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

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THE RELUCTANT RA

THE STUTTERING RA

THE ACHES ALL OVER RA

THE SNEEKY RA

THE PUFFY RA

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RHEUMATOID ARTHRITIS

AS MANY DOCTORS

MIGHT NOT KNOW IT

PRESENTATION

LABS

IMAGING

MANAGEMENT

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ABOUT

THE LABORATORY INVESTIGATIONS

IN RHEMATOID ARTHRITIS

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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

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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

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ESR

ESR IS NOT INVARIABLY ELEVATED

IN RA

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ABOUT THE IMAGING OF

RHEUMATOID ARTHRITIS

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BEFORE LOOKING FOR EROSIONS,

LOOK FIRST FOR:

JAO

JSN

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IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY

OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS

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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

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THE JOURNALIST’S HISTORY

THE POLICE OFFICER’S HISTORY

THE GOOD DOCTOR’S HISTORY

THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT:

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GOOD DOCTORS

DO NOT

DIAGNOSE DISEASES

THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES

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الأمراض مثل البشر ، لكل مرض ملامحه المميزة و طبائعه الخاصة التي يدرسها الطبيب ثم تزداد و تصقل معرفته بها بالممارسة و البحث و الإطلاع المستمر.

يتعرف الطبيب على هذه الملامح المميزة في أثناء الحوار مع المريض

وعلى هذا فإن أهم خطوة لتشخيص المرض هي:

الإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب

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ماذا يحدث بالإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب؟

يقع المريض في حفرة........

ماذا يفعل الطبيب في هذه الحالة؟

يسيبه يقع لوحده، ما يزقوش

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ABOUT THE MANAGEMENT OF

RHEUMATOID ARTHRITIS

slide36

MANAGEMENT OF RA COMPRISES:

PATIENT EDUCATION AND INSTRUCTIONS

MEDICAL TREATMENT

REHABILITATION

SURGICAL TREATMENT SOMETIMES

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MEDICAL TREATMENT

REHABILITATION

NSAIDs AND PHYSIOTHERAPY

Hydroxychloroquine, sulfasalazine, gold

Methotrexate, lefulonamide

Biological Agents

Aim of medical treatment:

Induction and maintenance of remission

slide39

Corticosteroids are not part of the medical treatment of RA except in very selected situations as:

Intra-articular

steroids

Bridge therapy

Severe

systemic

illness

slide41

THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST:

A CRIPPLING JOINT DISEASE

WITH A POSITIVE RF

AND NO TREATMENT

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PRESENTATION

  • A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION,
    • BUT
  • THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL
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PRESENTATION

THE MOST IMPORTANT STEP TOWARDS

A DIAGNOSIS OF RA IS

A GOOD HISTORY

TAKEN BY

A GOOD DOCTOR

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INVESTIGATIONS

A POSITIVE RF DOESN’T NECESSARILY MEAN RA

AND

A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA

slide45

INVESTIGATIONS

PLAIN FILMS IN EARLY RA

MAY BE NORMAL

slide46

MANAGEMENT

DOCTORS ARE MORE THAN JUST

TABLETS

slide47

MANAGEMENT

A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS

PATIENT EDUCATION

slide48

MANAGEMENT

CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF RA

EXCEPT IN

VERY SPECIAL SITUATIONS

slide49

MANAGEMENT

VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

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