RHEUMATOID

ARTHRITIS

By: Gaganpreet Kaur

 Introduction
 Rheumatoid arthritis is a chronic progressive inflammatory,
autoimmune disease mainly affecting peripheral synovial joints.
Basically it is a chronic systemic inflammatory disorder that may effect
any tissues and organs like heart, skin etc. but principally attacks the
joint.
 In joints, it produces proliferation and inflammatory synovitis that often
progress to destruction of the articular cartilage and ankylosis of the
joints.
 The chronic inflammation occurs due to continuous production of
autoantibodies called Rheumatoid arthritis factors (RA factor).
 In RA, this system no longer can differentiate self from non-self tissues
and attacks the synovial tissue and other connective tissues.
 ETIOLOGY
The cause of RA is not fully understood but appears to be multifactorial.
 It is considered an autoimmune disease in which the body loses its ability
to distinguish between synovial and foreign tissue.
Other factors involved in RA are as follows:
 Environmental influences, such as infections or trauma, are thought to
trigger the development of RA.
 Genetic markers, such as Human Leukocyte Antigen DR4 (HLA-DR4),
have been associated with triggering the inflammatory process in RA.
Such markers, however, are not considered diagnostic because 30% of
people with HLA-DR4 never develop RA.
 Antigen-dependent activation of T lymphocytes leads to proliferation
of the synovial lining, activation of proinflammatory cells from the bone
marrow, cytokine and protease secretion, and autoantibody production.
 Anti-citrullinated proteins and peptides are high specific for RA.
 Tumor necrosis factor & (TNF-&), IL-1, IL-6, IL-8, and growth
factors propagate the inflammatory process, and agents found to alter
these cytokines show promise in reducing pain and deformity.
Pathogenesis
 Pathogenesis
 Chronic inflammation of the synovial tissue lining the joint capsule
results in the proliferation of this tissue.
 The inflamed, proliferating synovium characteristic of rheumatoid
arthritis is called pannus.
 Pannus is a mass of synovium and synovial mass consisiting of
inflammatory cells, granulation tissue and fibroblasts.
 This pannus invades the cartilage and eventually the bone surface,
producing erosions of bone and cartilage and leading to destruction of
the joint.
 Signs and symptoms
 Fatigue and malaise
 Stiffness, especially in early morning and after sitting a long period
of time.
 Swollen, warm and painful joints.
 Low Grade Fever, Weakness.
 Muscle pain and pain with prolonged sitting.
 Symmetrical, affects joints on both sides of the body.
 Rheumatoid nodules: It is a local swelling or tissue lump, usually
rather firm to touch. They form close to joints affected by RA

 Deformity of your joints over time.

 Morphological Features
 ARTICULAR LESIONS:
RA involves first the small joints of hands and feet and then symmetrically
affects the joints of wrists, elbows, ankles and knees.
Histologically, the characteristic feature is diffuse proliferative synovitis
with formation of pannus.
The microscopic changes are as under
1. Numerous folds of large villi of synovium.
2. Marked thickening of the synovial membrane due to oedema, congestion
and multilayering of synoviocytes.
3. Intense inflammatory cell infiltrate in the synovial membrane with
predominance of lymphocytes, plasma cells and some macrophages, at
places forming lymphoid follicles.
4. Foci of fibrinoid necrosis and fibrin deposition.

 EXTRA-ARTICULAR LESIONS:
Nonspecific inflammatory changes are seen in the blood vessels (lungs,
pleura, myocardium, lymph nodes, peripheral nerves and eyes. But one of
the characteristic extra-articular manifestation of RA is occurrence of
rheumatoid nodules in the skin.
 Laboratory findings
 Rheumatoid factor (RF) is found in 60% of patients with RA;
however, as many as 5% of healthy individuals will have elevated titers
of RF. If initially negative, the test can be repeated in 6 to 12 months. RF
is not an accurate measure of disease progression.
 Erythrocyte sedimentation rate (ESR) and C-reactive protein
(CRP): They are markers of inflammation and are usually elevated in
patients with RA. They can also help indicate the activity of the disease,
but they do not indicate disease severity.
 Anticyclic citrullinated peptide antibodies (ACPA) :These are found
in most patients with RA and are useful in predicting erosive disease.
 Radiographic examination : This can reveal the extent of bone erosion
and cartilage loss. An MRI can detect proliferative pannus.
 Variants forms of RA
1. Juvenile RA found in adolescent patients under 16 years of age is
characterised by acute onset of fever and predominant involvement of
knees and ankles. Pathologic changes are similar but RF is rarely
present.
2. Felty’s syndrome consists of polyarticular RA associated with
splenomegaly and hypersplenism and consequent haematologic
derangements.
3. Ankylosing spondylitis or rheumatoid spondylitis is rheumatoid
involvement of the spine, particularly in young male patients. The
condition has a strong HLA-B27 association.