ABC of Rheumatology: RHEUMATOID ARTHRITIS--I: CLINICAL FEATURES AND DIAGNOSIS

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Abstract
Clinical features Joint damage The start of the disease is usually insidious but can be episodic or acute. Rheumatoid arthritis usually presents as a polyarthritis affecting small joints or small and large joints. Early disease is characterised by pain and other cardinal signs of inflammation (heat, swelling, functional loss, and possible erythema over the joints) but not by damage and deformity. If the disease remains active and uncontrolled the inflammation will usually spread to additional joints and gradual irreversible tissue damage will occur, causing deformity and instability of joints. The most serious long term disability is associated with damage to the larger weight bearing joints. View larger version: In this window In a new window FIG 1 Effect of rheumatoid arthritis on the hand: (left) early changes and (right) later deformity Inflammation of other synovial structures is common, and a similar process may occur in tendon sheaths, progressing to serious dysfunction and rupture. The typical rheumatoid deformities—such as ulnar deviation of the fingers, z deformity of the thumb, and swan neck and boutonniere deformities—are mostly due to damage or displacement of tendons. Palpable thickening or nodularity of tendons is common. Causes of impaired hand function in rheumatoid arthritis Active synovitis Joint deformity Rupture of tendon Carpal tunnel syndrome Mononeuritis Compression of nerve root at T1 Compression of spinal cord The spine—Although rheumatoid arthritis predominantly affects peripheral joints, discovertebral joints of the cervical spine are often affected. This may lead to atlantoaxial subluxation or, less commonly, subluxation at lower levels, with subsequent compression of the spinal cord. The earliest and most common symptom of cervical subluxation is pain radiating up into the occiput. Other symptoms include paraesthesia, sudden deterioration in hand function, sensory loss, abnormal gait, and urinary retention or incontinence. Effusion of the knee may produce a popliteal (Baker's) cyst. This may rupture to cause diffuse pain and swelling in the calf that mimics deep vein thrombosis. View larger version: In this window In a new window FIG 2 Magnetic resonance image of cervical spine showing spinal cord compression at C1 and C2. View larger version: In this window In a new window FIG 3 Rheumatoid nodule (above) and rheumatoid vasculitis (right). Extra-articular manifestations of rheumatoid arthritis Rheumatoid nodules Vasculitis Pulmonary Pleural effusion Fibrosing alveolitis Nodules Cardiac Pericarditis Mitral valve disease Conduction defects Skin Palmar erythema Cutaneous vasculitis Pyoderma gangrenosum

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