Diagnosis. Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other. Rheumatoid arthritis — Comprehensive overview covers signs, symptoms and treatment of this inflammatory arthritis. A primary care physician may suspect RA based in part on a person's signs and symptoms. If so, the patient will be referred to a rheumatologist – a specialist.
rheumatoid characteristics arthritis and of Diagnosis
The pattern of symptoms may wax and wane over the course of a day and even from one day to the next. A higher fever suggests another illness, and infectious causes must be considered, especially in patients who are taking biological therapies and immunosuppressive medications.
Morning stiffness, persisting more than one hour but often lasting several hours, may be a feature of any inflammatory arthritis but is especially characteristic of rheumatoid arthritis. Its duration is a useful gauge of the inflammatory activity of the disease. Similar stiffness can occur after long periods of sitting or inactivity gel phenomenon.
In contrast, patients with degenerative arthritis complain of stiffness lasting but a few minutes. Symmetrical joint swelling is characteristic of rheumatoid arthritis that has been persistent for a period of time.
However when only a few joints are affected at the beginning of disease, symmetry may not be seen and should not preclude the diagnosis of RA. Careful palpation of the joints can help to distinguish the swelling of joint inflammation from the bony enlargement seen in osteoarthritis, with the swelling often described as being doughy or spongy in RA in contrast to firm knobby enlargement in osteoarthritis.
Wrists, elbows, knees, ankles and MTP are other joints commonly affected where swelling is easily detected. Occasionally inflamed joints will feel warm to the touch. Inflammation, structural deformity, or both may limit the range of motion of the joint. Over time, some patients with RA develop deformities in the hands or feet. RA spares the distal joints of the fingers DIPs and the spine with the exception of the cervical spine especially the atlanto-axial joint at C1-C2 , which may become involved especially with longer standing disease.
Used by permission of the American College of Rheumatology. Permanent deformity is an unwanted result of the inflammatory process. Persistent tenosynovitis and synovitis leads to the formation of synovial cysts and to displaced or ruptured tendons. Extensor tendon rupture at the dorsum of the hand is a common and disabling problem. Although the joints are almost always the principal focus of RA, other organ systems may also be involved.
Extra-articular manifestations of RA occur most often in seropositive patients with more severe joint disease. The subcutaneous nodule is the most characteristic extra-articular lesion of the disease. Rarely, nodules may arise in visceral organs, such as the lungs, the heart, or the sclera of the eye. Atherosclerosis is the most common cardiovascular manifestation in rheumatoid arthritis. It is also the leading cause of death in the RA patient. Because chronic inflammation may be the cause of atherosclerosis, it is possible that early aggressive treatment of RA may reduce the incidence or severity of heart disease.
Pericarditis also seen with RA. Sicca dry eyes is a common complaint. Scleritis and corneal ulcerations are rare but more serious problems. It is important for patients to be seen regularly by the ophthalmologist and dentist. Additional medications are sometimes required to treat this condition. A polyclonal lymphoproliferative reaction characterized by lymphadenopathy is also seen, and patients have an increased risk of developing lymphoma.
The most common clinical manifestations of vasculitis are small digital infarcts along the nailbeds. The syndrome ordinarily emerges after years of seropositive, persistently active rheumatoid arthritis; however, vasculitis may occur when joints are inactive. Addional information on vasculitis can be found on our Vasculitis Center website. The most common neurologic manifestation of rheumatoid arthritis is a mild, primarily sensory peripheral neuropathy, usually more marked in the lower extremities.
Cervical myelopathy secondary to atlantoaxial subluxation is an uncommon but particularly worrisome complication potentially causing permanent, even fatal neurologic damage.
This is characterized by splenomegaly, and leukopenia — predominantly granulocytopenia. Recurrent bacterial infections and chronic refractory leg ulcers are the major complications.
The course of rheumatoid arthritis cannot be predicted in a given patient. Several patterns of activity have been described:. Recent studies have demonstrated an increased mortality in rheumatoid patients. Median life expectancy was shortened an average of 7 years for men and 3 years for women compared to control populations. In more than patients with rheumatoid arthritis from four centers, the mortality rate was two times greater than in the control population.
Patients at higher risk for shortened survival are those with systemic extra-articular involvement, low functional capacity, low socioeconomic status, low education, and prednisone use. Among patients with iUA, recognizing patients with progressive course particularly those who develop erosive disease is very important.
There is a great need to accurately predict the development of a well-defined diagnosis such as RA or other rheumatic diseases for initiation of treatment. Autoantibodies such as rheumatoid factor RF and anticylic citrullinated peptide antibodies anti-CCP have demonstrated high diagnostic specificity and can allow accurate prediction of RA in patients with UA.
In addition, some clinical or radiological features at baseline may also predict subsequent development of RA. In a study of recent onset arthritis, patients with mean disease duration of 3 months, over a median follow up period of 5 years, the presence of polyarticular disease predicted persistent arthritis and presence of hand arthritis t was the most predictor of a poor outcome Predictors of future development of rheumatoid arthritis in patients with recent onset arthritis.
In a French study of early cohort with inflammatory arthritis, presence of swollen joint count, morning stiffness, erosions, RF and anti-CCP at baseline were the most efficient predictors of future development of RA. Many rheumatic conditions can be diagnosed or suspected based on taking history and physical examination. Clinical findings are also the mainstay in selecting appropriate diagnostic laboratory tests requested for confirmation of RA or ruling out other rheumatic diseases Sometimes, diagnosis of RA may be possible based on clinical grounds alone, nevertheless there are no disease-specific clinical features or laboratory test to be diagnostic for RA.
The onset of RA as polyarticular disease develops insidiously in about three-quarters of patients. Early symptoms of RA may appear as vague pain with gradual appearance without classic symptoms of joint swelling or tenderness. These unusual symptoms are usually non-specific, and may persist for prolong period. Early articular manifestations of RA may be indistinguishable from other rheumatic diseases. Prolong duration of morning stiffness with arthralgia, or arthritis in a limited number of joints may be a clue for considering RA diagnosis 1.
Involvement of small joints of the hands or feet with swelling and tenderness particularly symmetric pattern of involvement along with positive compression test is highly suggestive of RA 27 , In a study of Quinn et al, painful joints of the hands at baseline were significant predictors of RA Presence of some clinical features such as polyarthritis, symmetric arthritis,hand arthritis, pain upon squeezing the metcarpophalangeal or metatasophalangeal joints, and morning stiffness greater than 30 minutes can be helpful not only in estimating the future course of arthritis but also in limiting the spectrum of differential diagnosis.
Identification of all involved joints by precise clinical examination is essential. Counting the tender and swollen joints, and calculation of disease activity score are logical methods for the determination of disease severity and response to treatment Abnormal values of the laboratory tests are the most typical features of RA.
The level of CRP was shown to be significantly correlated with the severity of disease as well as radiographic changes Arthrocynthesis and synovial fluid analysis can be also helpful for diagnosing inflammatory arthritis as well as in discriminating inflammatory from non-inflammatory arthritis. The diagnostic performance of synovial fluid anti-CCP was shown in a cross-sectional study. In this study, identification of anti-CCP in the synovial fluid of patients with arthritis demonstrated high discriminative ability in recognizing RA from non-RA diseases Acute phase reactants such as ESR and CRP are important tools for both confirmation and severity of inflammation in patients with arthritis.
Increased levels of these inflammatory markers suggest higher disease activity These tests may be also helpful in the evaluation of treatment efficacy. The levels of acute phase reactants decrease in correlation with efficiency of treatment as reflected by decrease in DAS value Radiographic signs of RA such as joint space narrowing, erosions and subluxation develop at later stage of RA process.
Plain radiography is the standard method in investigating the extent of anatomic changes in RA patients. However, there are few data regarding the value of conventional radiographic examination in recent-onset arthritis. Synovitis is the early findings of RA and is strong predictor of bone erosion. Soft tissue swelling and mild juxtaarticular osteoporosis may be the initial radiographic features of hand joints in early - RA These findings are representative of synovitis but cannot be shown on conventional radiogaraphs in all patients and are not precise enough and so are unreliable in the regular assessment of synovitis In particular, due to later occurrence of radiographic changes, plain radiography are insensitive for detection of bone erosion which is a characteristic for the diagnosis of RA 27 , In contrast sonography and MRI are more sensitive and seem promising but can be used in a limited centers, Sonography is a reliable technique that detect more erosion than radiography especially in early RA For these reasons, there is a trend toward early detection of RA bone erosions by MRI especially in patients with early signs of arthritis.
Presence of joint erosions in UA patients may be indicative of progression to RA. In a study by Tami et al. Sonography is also a reliable technique that detects more erosions than radiography especially in early RA. In early RA, sonography can detect greater number of erosions and in a greater number of patients than can radiography In addition, MRI is more sensitive than clinical examination to detect synovitis of hands and wrists in RA There is no specific test for diagnosis of RA. Recently, a new criteria has been developed for differentiating patients who may progress to RA according to ACR criteria from those who do not The aim of new criteria is the earlier identification of high risk early inflammatory arthritis for treatment, and preventing development of an arthritic disease that satisfies criteria.
This criteria provide data for earlier treatment and permit more rapid institution of DMADRs therapy. The new criteria rates on a scale from points were assigned in four separate domains of signs and symptoms namely: Patients are definitely diagnosed with RA if they score 6 or more points according to the following criteria table 2.
This criteria can be applied to any patient with at least one involved joint defined as clinical synovitis which can not be attributed to other entities and there is no explanation for synovitis The new classification criteria present a new approach with a specific emphasis on identifying patients with a relatively short duration of symptoms who may benefit from early instittuition of DMARD therapy.
Refers to any swollen or tender joint on examination. Distal interphalangeal,1st carpometacapeal and 1st tarsometatarseal joints are excluded from assessment.
Based on new developed criteria, patients with at least one involved joint may require DMARD therapy in respect to other components of criteria. RA disease may be considered a potentially curable condition during the evolutionary process from inflammatory arthritis to established condition and the disease course may be changed by early appropriate aggressive treatment Current knowledge and availability of highly efficient DMARDs or biological therapies encourage the goal of treatment being changed to achieve remission rather than control of inflammation Earlier identificatiin of high risk individuals and a very early use of effective DMARDs is a key point in patients at risk of developing persistent erosive arthritis This may provide opportunity for prevention of structural damages and long-term disability 3.
On the other hand, delay in starting treatment with DMARDs was shown to affect long-term outcome significantly A considerable proportion of UA patients are actually patients with RA in a very early phase and so it is important to identify UA patients who will develop RA and treat them as early as possible DMARDS are the mainstay of therapy and so should be initiated as early as possible in the course of the disease 1 their very early intervention was shown to be cost-effective Combination therapy is more effective than monotherapy and has a greater initial effect on clinical remission than on radiographic progression.
This study demonstated that combination therapy with 3 drugs for the first 2 years limited the peripheral joint damages for at least 5 years Combination therapy can be highly effective especially in patients with early RA. Initial combination therapy exerts greater protection for joint damage and provides earlier clinical improvements 9. Combination therapy using biological agents infliximab, adalimumab with methotrexate or biological therapy alone may induce remission in many patients with early RA.
Combination therapy should be considered in patients who have risk factors such as high level of anti-CCP, RF, joint erosion in radiographs and those who have shared epitope Results from previous studies suggest that treating high risk patients may slow the progression from early inflammatory arthritis to definite RA and inhibit the progression of joint damage Combination therapy can prevent radiographic progression even in patients with risk factors such as RF or anti-CCP whereas; monotherapy may be ineffective This regimen provides better outcome and should be considered in all patients 3 , Systemic glucocorticoids are also effective in the short-term relief of pain and swelling, and therefore may be considered for these purposes but mainly as a temporary therapy In addition, combination of steroids to DMARD therapy exerts additional effect on bone erosion see bellow.
Efficacy of treatment on joint damages on radiography. Long-term impact of early treatment on bone radiographic progression in RA was shown in a meta-analysis of 12 studies by Finckh et al. The benefits sustained for up to 5 years 5. Addition of prednisolone to DMARD therapy at the beginning of the initial treatment retards progression of radiographic damages.
This was illustrated in a study by Svensson et al. In 2 years, patients who received prednisolone 7. The corresponding remission rates in 2 years were In another similar study by Harfstrom et al. Over 4 years, the changes in bone density did not differ between the two groups In a systematic review, glucocorticoids substantially reduced the rate of progressive erosions in rheumatoid arthritis if given, in addition to standard therapy Disease course in RA varies across different studies.
In another study by Prevo et al. More than half of these cases achieved spontaneous remission In another study by Eberhardt et al. The long-term outcome of patients with early RA defined as disease duration less than 2 years was propectively assessed over 10 years by Lindqvist et al. In patients treated with prednisolone, remission rate was greater than those who did not take prednisolone The outcome of treatment in patients with recent-onset arthritis according to 4 treatment groups was determined by Allart et al.
Improvement appeared earlier and radiographic joint damages progression was significantly lower, remission rate was significantly higher in combination therapy than monotherapy. In addition, more patients could taper antirheumatic drugs and still retained remission and maintained higher life quality measures in formers groups than latter In conclusion, progressive course of RA may be mitigated or changed by appropriate treatment including combination of DMARDs started at earlier period.
Development of new criteria classify RA patients at early phase and permits initiation of treatment for suppression of inflammation and decreasing disease activity.
Early combination DMARDs is more effective than monotherapy and short duration of corticosteroid therapy added to treatment program exerts additional benefits in term of disease activity and bone erosions. National Center for Biotechnology Information , U. Caspian J Intern Med. Behzad Heidari , MD. Author information Article notes Copyright and License information Disclaimer.
Caspian Journal of Internal Medicine. This article has been cited by other articles in PMC. Abstract Rheumatoid arthritis RA is an inflammatory progressive disease which in the absence of appropriate treatment can lead to joint destruction and disability. Rheumatod arthritis, new criteria; early treatment, outcome. The importance of early diagnosis of RA Identification of RA at initial presentation and treatment at earlier stage can affect disease course, prevent the development of joint erosions or retard progression of erosive disease 5 , 9.
Prediction of early RA A patient with inflammatory arthritis may pass several stages from the onset of arthritis to a specific form of rheumatic diseases such as RA 8.
Table 1 Predictors of future development of rheumatoid arthritis in patients with recent onset arthritis. Open in a separate window. Clinical manifestations Many rheumatic conditions can be diagnosed or suspected based on taking history and physical examination.
Rheumatoid Arthritis Signs and Symptoms
Along with joint inflammation and pain, many people experience fatigue, loss of appetite and a low-grade fever. Because RA is a systemic disease, it may also. RHEUMATOID ARTHRITIS OVERVIEW. Rheumatoid arthritis is a chronic inflammatory condition. Rheumatoid arthritis symptoms develop. Rheumatoid arthritis is the UK's second most common arthritis. It causes joint pain and inflammation. Learn about the symptoms, causes and treatment.