1. Dr.jeries daoud • Consultant rheumatologist • RA

2. - R A : - is a chronic, systemic inflammatory disease of unknown etiology. • - Auto immune disease: - ployarticular pain and swolling -morning stiffness –malaise and fatigue.

3. Epidemiology • - Prevalence 0.5-1% • - Most commonly in women aged 30-50 years.

4. Etiology and Pathogenesis • - Gender: women before menopause are affected 3 times more than men. After menopause are similar • - Familial: the disease is familial but sporadic. • - H L A type: 50-70% H L A –D R 4.

5. Immunology

6. Immunology

7. Rheumatoid arthritis: synovitis, knee (photomicrograph)

8. Clinical presentation • - Typical Presentation &R A: • -Palindromic • - Transients. • - Chronic persistent. • - Rapidly progressive.

9. Symptom and Sign's • - The majority complain: - pain –stiffness of small joints of the hands • (M C P-P I P) , M T P. • - Wrists, Elbows, Shoulder's, knee's and Ankles. • -90% -Poly articular . • -10% -mono articular. • . R A • Although R A is manifested primarily by joint involvement most patients experience such non specific systemic symptoms. Fatigue .malaise. • Low grade fever and depression.

10. Joint involvement in R A • Hand and wrists • * Early disease: finger's are • Swollen, painful and stiff. • * Inflamed flexor tender. • * C T S • Deformity: • . ulnar devation • .palmer sublaxation of M C P • . Swan neck deformity • . Boutonniere deformity • . Z deformity of thumb

12. Rheumatoid arthritis: subluxation and muscle artrophy, hands

13. Rheumatoid arthritis: ulnar deviation and muscle artrophy, hands

14. Rheumatoid arthritis: swan-neck and boutonnière deformity, hand

15. Elbow's • Elbow's: synovitis swelling and painful fixed flexion deformity.

16. Shoulders • Shoulders : initially mimic rotar cuff tendonitis "painful arch syndrome"---global stiffening ---rotar cuff tear.

17. Feet • Feet: -one of the earliest manifestation of RA. • - Painful, swelling MTP. • - Foot become broader and hammers - toe deformity. • - Ulcers or callouses may develop over metatarsal heads and dorsum of the toes. • -Hallus valgus. • - Mid and hind foot RA causes a flat medial arch and loss of flexibility of the foot. • - Ankle ---- valgus position .

18. Rheumatoid arthritis: protruding metatarsal heads

19. Knees • Knees: massive synovitis and effusions---baker cyst----knee-varus or valgus deformity. • -----secondary O A.

21. Hips • Hips: - rarely in early R A. • - the latter may permit medial migration of the acetabulum (protrusion acetabulae).

22. Rheumatoid arthritis: hip, late erosions (radiographs)

23. Rheumatoid arthritis: hip, protrusio acetabuli (radiograph)

24. Cervical spine: painful stiffness of the neck. • In R A is often muscular "but may be due to synovitis".

25. Extraarticular mauifestion • *Rheumatoid nodules :firm intradermal and generally occur over pressure point.

26. Rheumatoid arthritis: subcutaneous nodule, olecranon

27. Lungs: • -serositis ---pleural effusion • -lung nodules • -Caplan syndrome • -Fibrosing alveolitis • -Obstructive bronchiolitis

29. Rheumatoid arthritis: Caplan’s syndrome (radiograph)

30. Vasculitis • -Nail-fold infarctions • -Wide spread cutaneous vasculitis • -Mononeuritis multiplex • -Bowel infarction

31. Rheumatoid arthritis: vasculitis with small infarcts, fingers

32. Heart • Pericarditis

33. The nerveous system • -Neuropathy • -Compressing neuropathy (CTS,Tarsal tunnal syndrome)

34. The eyes • -scleritis • -Episcleritis • -Sclero malacia perforans • -Sicca syndrome

35. Rheumatoid arthritis: episcleritis

36. Rheumatoid arthritis: scleroderma

37. Rheumatoid arthritis: scleromalacia perforans

38. The kidneys • -amyloidosis • -Drugs

39. Felty’s syndrome • Seropositive rheumatoid arthritis • Splenomegaly • Leukopenia (neutropenia) • Recurrent infections • Leg ulcers

40. Investigations • -Anemia • -Leukocytosis • -ESR • -Crp • -RA 70% • -anticcp:anti cyclic citrullenated peptide • -ANA 30%

41. Rheumatoid factors (diagram)

42. Rheumatoid factor in rheumatic disease • Rheumatoid arthritis • Systemic lupus erythematosus • Sjögren's syndrome • Systemic sclerosis • Dermatomyositis/polymyositis • Vasculitis • Cryoglobulinemia • Juvenile rheumatoid arthritis

43. Viral infections Hepatitis C (also A & B) Parvovirus Rubella CMV HIV EBV Parasitic diseases Rheumatoid factor in nonrheumatic diseases • Normal individuals (< 5%) • Elderly • Bacterial infections • Endocarditis • Leprosy • Syphilis • Lyme disease • Periodontal disease

44. Rheumatoid factor in nonrheumatic diseases • Lymphoproliferative disease • Interstitial lung disease • Chronic liver disease • Sarcoidosis • Post-vaccination • Malignancies

45. Radiographic features of rheumatoid arthritis • Periarticular soft-tissue swelling • Juxtaarticular osteopenia • Marginal erosions • Joint-space narrowing • Symmetric involvement • Deformities in advanced disease

46. Rheumatoid arthritis: hand, progressive metacarpophalangeal erosion (radiographs)

48. Rheumatoid arthritis: wrist erosion (radiographs)

49. Rheumatoid arthritis: metatarsal erosion (radiograph)

50. ACR 1987 criteria for the classification of acute rheumatoid arthritis • Need at least four of seven criteria: • 1. Morning stiffness lasting at least 1 hr • 2. Soft- tissue swelling or fluid in at least 3 joint areas simultaneously • 3. At least one area swollen in a wrist, MCP, or PIP joint* • 4. Symmetric arthritis* • 5. Rheumatoid nodules • 6. Abnormal amounts of serum rheumatoid factor • 7. Erosions or bony decalcification on radiographs of the hand and wrist • * For classification purposes, a patient shall be said to have rheumatoid arthritis if he/she has satisfied at least 4 or these 7 criteria. Criteria 1 through 4 must have been present for at least 6 weeks.