Rheumatoid Arthritis (RA)

 

As mentioned in the introductory pages of this website, the word “arth” means joint and the word “itis” means inflammation. Hence “arthritis” means “inflammation in the joints”. In various languages and communities it is known differently.

This disease is characterized by pains and swelling in multiple joints. Hence often referred to as “polyarticular” (“poly” means multiple usually more than 5 and “articular” meaning related to joints).

Quite typically RA is characterized by a symmetrical form of arthritis which means that there is symmetrical involvement of the joints: if the left wrist is involved then the right wrist will also be or if the right knee is affected then there will be affection of its partner as well.

One more important feature is that both small and large joints are involved in this disease meaning finger joints as well as larger joints such as knees etc. contrast this with “Spondyloarthropathy” or “Ankylosing spondylitis” where the disease is usually asymmetric and involves the larger joints.

Additionally the spine is spared in RA except for the cervical spine meaning the neck region.

Rheumatoid arthritis is a “systemic disease” meaning it affects the entire body. Do not think that only the joints are involved this disease can affect the eyes and the lungs as well.

People with uncontrolled arthritis are known to have a shorter life span than the average life span of the population. This is because the chronic inflammation also affects the blood vessels and thereon the heart. Hence it is imperative to treat this disease as aggressively as you would any other systemic illness.

 Untreated arthritis leads to permanent Joint damage and deformities. Joint damage once it has occurred is permanent meaning it cannot be reversed. What is lost is lost. You can only try and prevent further damage in the joint by controlling the inflammation with Anti-rheumatic drugs known as DMARDS (disease modifying anti-rheumatic drugs).

It is known that if untreated for 6 months 80 percent of patients begin to show signs of cartilage affection and joint damage. It is also an established fact that if treatment is begun within the first 6 weeks then the patient stands a chance of remission which means a “cure”. Even if that does not happen and medications need to be continued joint damage will be prevented and a good quality of life will be ensured.

Hence please consult a rheumatologist ASAP (as early as possible) and have this illness treated appropriately. The majority of patients consult an orthopedic surgeon for this problem. Orthopedic surgeons are “Surgeons” and are not trained to understand this disease in its totality. Their training is in surgery and they treat fractures or conduct Joint replacements etc. They are not trained to treat Rheumatic diseases which is a different specialty altogether.

 Rheumatologists are physicians who specialize in Rheumatology AFTER their MD in medicine or pediatrics in case of pediatric rheumatology.

 

Diagnosing Rheumatoid Arthritis:

The diagnosis of RA is essentially a clinical diagnosis based on Symptoms, Signs and Clinical Examination. There are no tests meant to diagnose arthritis, though there are certain tests which support establishing the diagnosis of RA.

For example let us take Rheumatoid factor or RF. This test is erroneously referred to as “RA test”. There is no such thing as RA test. This is a misnomer. Even some Pathology labs issue reports which refer to this as RA test which is wrong.

Now let us talk about this test. This test even in cases of RA is positive in about 66% of patients. Effectively this means that 33% of patients who do have RA will not be diagnosed if you rely on this test. Even patients who have aggressive disease can have a negative rheumatoid factor(Sero negative RA).

Cyclic Citrullinated Peptide (Anti CCP sometimes referred by a few as ACPA): This is a more specific test for RA meaning if this test is positive there is a significant possibility that you do have RA. Again the titres are important. But more importantly if this test is negative it still does not mean you do not have RA.

On the other hand we see a lot of patients being treated with anti-rheumatic drugs by Orthopedic surgeons when they do not have RA at all. The patient has joint pains and so start treatment. What is important here is to diagnose correctly and treat on time else there will be complications on both sides. 

 

Rheumatoid Arthritis Treatment:

1) Disease modifying anti-rheumatic drugs (DMARDS):
These are not painkillers or steroids but anti rheumatic drugs meant to control the inflammatory process itself. They are slow acting drugs and take a minimum of 6 to 8 weeks to show any benefit. The patient will feel relief only when the inflammatory process itself is controlled.

Beyond these drugs are biological agents which are extremely powerful anti-rheumatic drugs. These drugs have brought about a revolution in rheumatoid arthritis treatment.  However these drugs come with their own set of conditions.

 a) They are extremely expensive and hence beyond the reach of the majority of middle class patients also so forget the lower class.
 b) These drugs are extremely powerful immunosuppressants. Given the level of hygiene in our country and the number of infections that our country is endemic for, these drugs will need to be used very cautiously after careful screening of each patient for any underlying infection right from head to toe.

2) Non-steroidal Anti- inflammatory agents (NSAIDs): Commonly called painkillers however not all painkillers are anti-inflammatory. These have a short lived but important role in the initial relief of pain. As mentioned above, DMARDS take 6-8 weeks to act at the least. Hence to tide over this initial period one would need to use these drugs for a short while. However these are not anti-rheumatic drugs and cannot be continued indefinitely as they will then lead to side effects. NSAIDS have been dealt with separately in the drugs section.

3) Steroids: These have almost become a Taboo word amongst the masses for all the wrong reasons. Yes they can have a lot of side effects but if used by the wrong people in the wrong condition in the wrong dose for a wrong period of time, they can definitely cause problems. But remember steroids were meant to be lifesaving drugs and not meant to cause side effects. They have gained a bad reputation because they have been used in the wrong indications.

4) Exercise: Regular exercise is a must which no one pays much attention to. We hear excuses and excuses to avoid exercise.
Remember if you do not treat RA on time you will miss the boat. This disease will keep progressing and affect so many functions of our body that it takes the very joy out of living. Once that happens life becomes an endless misery.  So start arthritis treatment early and control the disease aggressively. AS are weak already and such activities may result in fractures.

 

Ankylosing Spondylitis (AS)

As mentioned elsewhere in the introduction the word “itis” is stands for inflammation. The word “spondy “signifies related to the spine hence “Spondylitis” effectively means Inflammation in the spine.
 The word Ankylosing means to join together or fuse. In Toto the phrase “Ankylosing Spondylitis” effectively means “inflammation in the spine leading to joining or fusion of the spine”.
The common symptoms of this Ankylosing Spondylitis(AS) comprise of the following:
1)   Onset of low back pain or buttock pain in young individuals between the ages of 18 to 30.
2)   Sometimes buttock pain alternates between left and right side.
3)   This pain is associated with stiffness which is much worse in the morning after rest called “early morning stiffness” (EMS) and may last 30 minutes sometimes even more.
4)   In some patients the stiffness increases in the middle of the night waking the patient from his sleep. The pain and stiffness reduce after a period of activity or exercise.
5)      Anti- inflammatory drugs (NSAIDS or non-steroidal anti-inflammatory drugs)provide significant relief in the pain.
6)      Hip joint involvement characterized by groin pain is quite common.

 

Scleroderma (Systemic Sclerosis)

The word Scleroderma means hard skin (Sclero = hard and derma = skin).

This is a rheumatic disease characterized by thickening of the skin either in one area of the body called Localized Scleroderma or thickening of the skin along with affection of the internal organs in which case it is called Systemic Sclerosis.
This disease like many others affects women more than men usually between 20 and 40 years of age. Let us address the Systemic Sclerosis first as this has larger ramifications in terms of the life span and quality of life of an individual.
 This disease is characterized bythickening, tightening of the skin along with darkening resulting from deposition of a substance called collagen in the skin and other organs.
This classification is mainly based on the area of skin involvement. In the limited variety a relatively lesser area of skin is involved whereas in the diffuse variety the entire body is involved.

a) Limited Cutaneous: In the limited form the skin affection is restricted to the face and the peripheral parts of the body such as the upper limbs up to the forearms and legs up to the knees and spares the trunk.
b) Diffuse Cutaneous: Here the skin is extensively involved hardly sparing any area of the body including the trunk. This is a relatively aggressive disease with maximal affection within the first 3 years itself after which the disease begins to plateau gradually. However by this time, damage to the internal organs has already occurred.
Features:

  1. Raynaud’s Phenomenon
  2. Skinthickening
  3. Sclerodactyly
  4. Calcinosis
  5. Telangiectasia
  6. Gastro-esophagealdys Function
  7. Arthralgia and Arthritis
  8. Lung Involvement
  9. Cardiac Involvement
  10. Kidney Involvement

 

Diagnosing Scleroderma (Systemic Sclerosis)

As with most Rheumatic diseases, the diagnosis is a clinical one and there are no magic tests that one can perform to arrive at the diagnosis. However once diagnosed by your rheumatologist you will need multiple tests to assess degree of organ involvement by the disease.

Antiphospholipid Antibody Syndrome (APLS; APS)

 

“Antiphospholipid Antibody Syndrome” is an immune disorder characterized by a hypercoagulable state meaning it is a condition characterised by tendency to develop clots in medium to large arteries or large veins.
As a result the patient has a tendency towards development of clots in any organ of the body. A few examples of these clots leading to complications are given below:

1) Large veins causing a condition called DVT (Deep Vein Thrombosis).
2) Blood clots in large veins may break off and get lodged in the arteries of the Lungs causing a life threatening condition called “Pulmonary Embolism”.
 3) Similarly clots in the arteries of the heart can lead to heart attacks, or in the brain giving rise to strokes, or even intestines causing Intestinal gangrene etc.

 

 

Ankylosing Spondylitis


Ankylosing spondylitis is a type of arthritis that affects the spine. Ankylosing spondylitis symptoms include pain and stiffness fromthe neck down to the lower back.

Who Is Affected by Ankylosing Spondylitis?

 

Ankylosing spondylitis affects about 0.1% to 0.5% of the adult population. Although it can occur at any age, spondylitis most often strikes men in their teens and 20s.

 

Symptoms of Ankylosing Spondylitis

 

Pain and stiffness. Constant pain and stiffness in the low back, buttocks, and hips that continue for more than three months.

Bony fusion. Ankylosing spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of bones, called "bony fusion." Fusion affecting bones of the neck, back, or hips may impair a person's ability to perform routine activities.

Pain in ligaments and tendons. Spondylitis also may affect some of the ligaments and tendons that attach to bones.

 

 

Systemic lupus


Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs.

SLE is a chronic disease that can have phases of worsening symptoms that alternate with periods of mild symptoms. Luckily, most people with SLE lead a normal life.

Causes of SLE

 

Genetics The disease is not linked to a certain gene, but people with lupus often have family members with other autoimmune conditions

Environment There may be environmental triggers like ultraviolet rays, certain medications, a virus, physical or emotional stress, and trauma.

Gender and Hormones SLE affects more women than men. Women also experience worsening of symptoms during pregnancy and with their menstrual periods.

 

 

Erythematosus


Erythematosus is a name given to a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks normal, healthy tissues. Symptoms of these diseases can affect many different body systems, including joints, skin, kidneys, blood cells, heart, and lungs.

This topic focuses on systemic lupus erythematosus (SLE), the most common and most serious type of lupus. But there are other types of lupus, such as discoid or cutaneous lupus, drug-induced systemic lupus, and neonatal lupus.

Causes of SLE

 

The exact cause of lupus is not known. Experts believe that some people are born with certain genes that affect how the immune system works.

Lupus symptoms vary widely, and they come and go. The times when symptoms get worse are called relapses, or flares. The times when symptoms are under control are called remissions.

 

 

Polymyositis


Polymyositis is a rare inflammatory disease that leads to muscle weakness, swelling tenderness, and tissue damage. It is part of a larger group of diseases called myositis.back.

Causes

 

Polymyositis affects the skeletal muscles. It is also known as idiopathic inflammatory myopathy. The exact cause is unknown, but it may be related to an autoimmune reaction or infection.

Polymyositis can affect people at any age. It most common in adults between ages 50 and 70, and in children ages 5 to 15. It affects women twice as often as men. It is more common in African Americans than Caucasians.

 

Symptoms

 

• Difficulty swallowing

• Muscle pain

• Muscle weakness in the proximal muscles (shoulders, hips, etc.) this can make it hard to raise the arms over the head, get up from a sitting position, or climb stairs

• Problems with the voice (caused by weak throat muscles)

• Shortness of breath

• Fatigue

• Fever

• Joint pain

• Loss of appetite

• Morning stiffness

• Weight loss

 

 

Dermatomyositis


Dermatomyositis is a rare inflammatory disease. It is an inflammatory myopathy, a condition that occurs when muscles become inflamed. It is one of only three known inflammatory myopathies. The most common symptom is weakness in the muscles.

Symptoms

 

In most cases, the most obvious symptom is a skin rash on the face, chest, nails, or elbows that can appear to be red or violet.

• muscle pain

• muscle tenderness

• problems swallowing

• lung problems

• hard calcium deposits underneath the skin (mostly seen in children)

• Fatigue

• Fever

• unintentional weight loss

 

 

Stills Disease


Still's disease is a form of arthritis characterized by high spiking fevers, salmon-coloured rashes and inflammation of the joints. The disease is most common among children, for whom it is commonly referred to as systemic juvenile idiopathic arthritis. Still's disease accounts for 10-20 percent of all cases of juvenile arthritis. It is significantly less common among adults

Causes

 

There have been a number of schools of thought. One is that Still’s disease is due to infection with a microbe. Another concept is that Still’s disease is a hypersensitive or autoimmune disorder. In truth, the cause of Still’s disease is still not known.

 

Common Symptoms

 

• A fever that comes on quickly once per day, usually in the afternoon or evening.

• Joint pain, warmth, and swelling affecting a few joints at first -- often knees and wrists -- then several joints,

• A salmon pink-colored skin rash that usually comes and goes with the fever and usually doesn't itch.

• Severe muscle aches, which also may ebb with the fever.

• A sore throat that can be severe, constant, and burning.

• Abdominal pain and swelling

• Pain when taking a deep breath

• Swollen glands (lymph nodes)

• Unexplained weight loss

 

 

Felty's syndrome


Felty's syndrome, also called Felty syndrome, is characterized by the combination of rheumatoid arthritis, splenomegaly and neutropenia. The condition is more common in those aged 50-70 years, and is more prevalent in females than males and more in Caucasians than blacks.

Causes

 

The cause of FS is not known, however there are indications that a number of factors can contribute to this condition. White blood cells, produced in the bone marrow, might be developing abnormally.

 

Common Symptoms

 

• Fatigue.

• Anorexia.

• Weight loss.

• Eye symptoms (including dry eyes and irritation due to Sjögren's syndrome and red and painful eyes due to episcleritis).

• Recurrent infections due to neutropenia (lung and skin infections are most common).

• Left upper quadrant pain (due to splenomegaly or splenic infarcts).

• Symptoms related to RA, including joint swelling, pain, stiffness and deformity.

 

 

Scleroderma


a chronic hardening and contraction of the skin and connective tissue, either locally or throughout the body.


Scleroderma is classified as an autoimmune disease. This means that a person’s immune system works against itself. The normal immune system protects the body by fighting off foreign invaders such as viruses and infections.

In scleroderma, cells start making collagen as if there were an injury that needs repairing. The cells do not turn off as they should and end up making too much collagen.

Symptoms

 

• Fingers that become very sensitive to cold and change color with cold or emotional stress: Raynaud’s phenomenon

• Fingers and hands that become stiff and puffy

 

 

Sjögren's syndrome


Sjögren's (pronounced SHOW-grins) syndrome (SS) is a chronic, autoimmune disease in which white blood cells attack and destroy the moisture-producing glands, causing decreased production of saliva and tears. It was first identified by a Swedish physician, Dr. Henrik Sjögren in 1933.


Causes

 

i) Genetic factors

ii) Hormonal factors

iii) Microchimerism factors

iv) Environmental (exogenous) factors

 

 

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