1. Rheumatoid Arthritis Extra-articular
Rh Extensor surfaces of the forearms, scalp, sacrum, scapula, Achilles tendon,
nodules fingers & toes.
Epidemiology May cause trigger finger
Usually middle aged, female > males (3:1) Indicates Rh factor + and more aggressive dz
Genetics: HLA-DR4 linked Eyes: Episcleritis
Scleritis
RA Diagnostic Criteria (American Rheumatism Association) Keratoconjunctivitis sicca – look for other signs of Sjögren’s syndrome
Dx of RA made when ≥4 criteria are met: (xerostomia, parotid enlargement)
Morning stiffness (>1hr) Lungs: Pulmonary fibrosis
Arthritis of ≥3 joints ≥6 weeks
Pleural effusions
Arthritis of hand joints Pleurisy
Arthritis is symmetrical Rheumatoid nodules
Rheumatoid nodules CVS Peri-/Myo-/Endo-carditis
Rheumatoid factor + Pericardial effusion
Radiological changes Conduction defects
Neuro: Entrapment neuropathies – carpal tunnel syndrome (median n), ulnar n @
Typical Presentation elbow, peroneal n. @ knee, post. tibial n. @ ankle
Cervical cord compression
Chronic inflammatory joint dz, relapsing & remitting course
Compression neuropathies
Symmetrical deforming peripheral polyarthritis
Mononeuritis multiplex
Classically swollen, painful and stiff hands & feet, worse in the mornings
Peripheral neuropathy
Insidious onset, affecting small joints first, progressing to large jt involvement
Extra-articular symptoms: Haemato Anaemia – due to chronic dz, folate def, assoc pernicious anaemia, Felty’s
o Fever, LOW/LOA, fatigue, myalgia synd. or drugs (NSAIDs, gold)
o Others (see extra-articular signs of RA) Felty’s syndrome: RA + splenomegaly + hypersplenism (anaemia, neutropenia
Atypical presentations: & thrombocytopenia) + leg ulcers.
o Palindromic: relapsing/remitting monoarthritis of large jts Vasculitis Nail-fold infarcts
o Persistent Monoarthritis Digital gangrene
o Systemic: pericarditis, pleurisy, LOW, constitutional symptoms Leg ulcers/purpura
o Acute onset widespread arthritis Skin necrosis
Musculo- Ruptured tendons
skeletal Muscle weakness & wasting
Signs Osteoporosis
Hand & Joints Tenosynovitis & bursitis
Hand signs Other joint involvement Others Lymphadenopathy
Vasculitis – nail-fold infarct, vasculitic skin lesions Feet Amyloidosis
Sausage shaped fingers o Clawing of toes
Ulnar deviation of fingers o MTPJ subluxation
Swan-neck deformities o Valgus deformity of subtalar Short case Approach to RA
Boutonniere deformities jt 1) Comment on hand signs and distribution of arthropathy (ie symmetrical polyarthritis) –
Z deformity of the thumbs Large joint involvement highlight sparing of DIPJ and comment if RA is active (presence of jt inflammation)
PIPJ & MCPJ swelling (DIPJ usu spared) Atlanto-axial jt subluxation – 2) Test grip & pincer movts
Volar subluxation @ MCP jts potential cervical cord 3) Test muscles:
Wrist subluxation compression a) abduct thumb (abductor pollicis brevis – median n)
Piano-key (prominent radial head) b) abduct fingers (dorsal interossei – ulnar n.)
Palmar erythema 4) Test pinprick sensation:
st
Wasting of 1 dorsal interossei & small muscles a) index finger (median n.)
of the hand b) little finger (ulnar n.)
Ruptured tendons of the hand 5) Test for carpal tunnel syndrome – Phalen’s test (full flexion for 1 min); Tinel’s sign
↓ ROM (gentle percussion)

2. 6) Rheumatoid nodules – inspect elbows ulcers. (monitor urine for bld & protein & FBC)
7) Functional assessment – writing, buttoning D-penicillamine SE: n/v, rash, proteinuria & nephrotic syndrome, cytopenias (monitor
with urinalysis & FBC)
Invx May ppt other autoimmune dz (eg SLE, MG)
FBC Normocytic normochromic anaemia Corticosteroids For severe dz/exacerbations not responding to other drugs
WCC ↓ Use lowest dose possible. Risk of long term SE
Pltlets ↑ Rebound dz common on stopping steroids.
ESR & CRP ↑ Intra-lesional steroids – useful for treating 1-2 inflamed jts not
Rh factor + in 80% controlled by systemic Rx, bursitis, tenosynovitis, carpal tunnel
also + in Sjögren’s, SLE, mixed CT dz & systemic sclerosis syndrome. Avoid repeated injections esp in large jts.
ANA + in 30% Other cytotoxic Azathioprine, cyclophosphamide, cyclosporin A
X-ray joints Soft tissue swelling drugs Indication: severe dz with failure of other therapies
Juxta-articular osteoporosis Surgery To improve function
↓ jt space Eg synovectomy & decompression of wrist & tendon sheaths, tendon
Bony erosion at joint margins repair & transfer, arthrodesis, osteotomy, arthroplasties, jt
± subluxation replacement
± complete carpal destruction Paramedical Regular exercise
Jt dislocation services Physiotherapy
X-ray lat C-spine Atlanto-axial subluxation (↑ pre-odontoid gap) Occupational therapy – adaptive aids, orthoses (eg wrist splints),
Caution during intubation ADL training
Synovial analysis Turbid Sjögren’s syndrome Oral hygiene, artificial tears
↓ viscosity Splenectomy for PTs with serious infections
Clots Others PT education
Drug safety monitoring FBC Support groups
Urinalysis *Drugs causing cytopenias: warn PT to stop med and consult doctor if sore throat devts
LFT
Creatinine Complications
Septic arthritis
Treatment Amyloidosis
Symptomatic Pain: paracetamol, paracetamol/codeine, NSAIDs (eg aspirin), COX-
2 inhibitors Poor Prognostic Factors
NSAIDs (eg diclofenac, indomethacin, ibuprofen) 1) Female
⇒ Beware of GI SE – avoid in PTs with hx of PUD & elderly. Give 2) Old age at onset
H2RA or PPI 3) HLA-DR4
⇒ Other SE – interstitial nephritis, fluid retention, hepatotoxicity 4) Insidious onset
Rest joints 5) Systemic features: LOW, extra-articular manifestations of RA
DMARDs (mono- or combination therapy) 6) Greater number of jts affected
7) Uncontrolled polyarthritis
Hydroxychloroquine For mild dz
8) Persistent dz activity >12 mths
SE: macular pigmentation, retinopathy, rash, nausea, diarrhoea,
9) Rheumatoid nodules
hemolytic anaemia, ototoxicity, aggravate psoriasis
10) Vasculitis
Sulphasalazine For moderate dz
11) Rh factor > 1 in 512
SE: SJS, n/v, headache, drug-induced hepatitis & cytopenias
12) Early bone erosions, structural damage/deformity
⇒ Monitor LFT & FBC at 3 & 6 mths
Methotrexate SE: cytopenias, hepatitis (monitor LFT & FBC 6-8 wkly)
⇒ Give with folic acid to reduce GI SE Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY,
Lefluonomide SE: as for MTX, + alopecia, diarrhoea, rash o=UCSI University, School of Medicine, KT-
Campus, Terengganu, ou=Internal Medicine
Gold salts Less frequently used now due to better drugs w less SE Group, email=wunna.hlashwe@gmail.com
SE: glomerulonephritis, cytopenias, exfoliative dermatitis, mouth Reason: This document is for UCSI year 4
students.
Date: 2009.02.24 10:50:03 +08'00'