Hatem H Eleishi, MDProfessor of Rheumatology, Cairo UniversityConsultant Rheumatologist, Dr. Soliman Fakeeh Hospital

Rheumatoid ArthritisWednesday, April 29th, 2009

Lecture 1Rheumatoid Arthritis

From the General Practitioner’s Perspectiveto the Basic Rheumatologist’s Perspective

WHAT MANY DOCTORS KNOW ABOUT RHEUMATOID ARTHRITIS

WHAT MANY DOCTORS MIGHT NOT KNOW ABOUT RHEUMATOID ARTHRITIS

IN THIS LECTURE

RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT

CLINICALLY:POLYARTHRITISIN TIME, CRIPPLING JOINT DEFORMITIES

LABORATORY: POSITIVE RF, HIGH ESR

PLAIN RADIOLOGY: ARTICULAR EROSIONS

MANAGEMENT: NO REAL TREATMENT; ONLY NSAIDs, MAY BE STEROIDSMTX WHICH IS VERY TOXIC

AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY:

IN SHORT

A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT

RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT

PRESENTATION LABS IMAGING MANAGEMENT

ABOUT THE PRESENTATION OFRHEUMATOID ARTHRITIS

IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO;

TRUE: THE MOST COMMON PRESENTATION ISA SYMMETRICAL POLYARTHRITIS

WE HAVE

THE RELUCTANT RA

THE STUTTERING RA

THE DISGUISED RA

THE ACHES ALL OVER RA

THE PUFFY RA

A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS.

DURATION OF EACH ATTACK: 3-7 DAYS

ATTACK FREE PERIOD: 2-3 MONHTS

THE RELUCTANT RA

OR PALINDROMIC RHEUMATISM

PRESENTATION 1 OF 5

2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRISTPLAIN FILM OF HER HANDS: NORMALMRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA

EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST

S T U T T E R I N G RA

LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES

ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS

PRESENTATION 2 OF 5

RA RA

FEMALE; 48Y-OLDOA KNEES / HANDS

LATELY PAINNOCTURNAL PAINSREC EFFUSIONS

PLAINS: OAESR 50RF +VESYNOVIONALYSIS: INFLAMMATORY SF

RA ON TOP OF OA OR DISGUISED RA

PRESENTATION 3 OF 5

Mona, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of 10-60 minutes and nocturnal pain sometimes.

She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative.

PRESENTATION 4 OF 5

Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs.

Investigations: ESR 21CBC, liver, kidney, electrolytes: normalRF; ANA: negativeHepatitis serology: negativeA plain film of the hands and feet were normal

DIFFUSE ACHES ALL OVER RA

OR FIBROMYALGIC RA

A Tc99 bone scan was done

Early rheumatoid arthritis can sometimes be

a vague diagnosis

Bone scan helps to settle the diagnosis

in such situations

Abu-Ismail, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hoursExamination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wristsLABS: ESR 70; Hb 11gm%; RF: Negative

RS3PE REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS

WITH PITTING EDEMA OR PUFFY RA

PRESENTATION 5 OF 5

THE RELUCTANT RA

THE STUTTERING RA

THE SNEEKY RA

THE ACHES ALL OVER RA

THE PUFFY RA

RHEUMATOID ARTHRITIS

AS MANY DOCTORS MIGHT NOT KNOW IT

PRESENTATION LABS IMAGING MANAGEMENT

ABOUT THE LABORATORY INVESTIGATIONS

IN RHEMATOID ARTHRITIS

THERE ARE CAUSES FOR A POSITIVE RF OTHER THAN RA

SO YOU CANNOT RELY SOLELY ON A POSITIVE RF TO DIAGNOSE RA

POSITIVE RHEUMATOID FACTOR“THE RHEUMATOID CETRTIFICATE”

RHEUMATOID FACTOR IS POSITIVE IN ONLY 70% OF PATIENTS AND NEGATIVE IN 30%

SO A NEGATIVE RF DOESN’T RELIABLY EXCLUDE RA

NEGATIVE RHEUMATOID FACTOR

ESR IS NOT INVARIABLY ELEVATEDIN RA

ESR

ABOUT THE IMAGING OFRHEUMATOID ARTHRITIS

NOT EVERY RHEUMATOID DISEASE IS NECESSARILY EROSIVE

BEFORE LOOKING FOR EROSIONS, LOOK FIRST FOR: JAOJSN

IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY

OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS

What is the most important thing that is needed to make the diagnosis of RA?

A good lab

An imaging center

A chair

A screening questionnaire for the population

Knowing the family history of your patient

Two doctors rather than one

HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO THE CORRECT DIAGNOSIS

THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT:

THE POLICE OFFICER’S HISTORY

THE JOURNALIST’S HISTORY

THE GOOD DOCTOR’S HISTORY

GOOD DOCTORS DO NOT

DIAGNOSE DISEASES

THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES

لكل ، البشر مثل األمراضو المميزة مالمحه مرضالتي الخاصة طبائعهو تزداد ثم الطبيب يدرسهابها معرفته تصقلو البحث و بالممارسة

المستمر .اإلطالع

أثناء في المميزة المالمح هذه على الطبيب يتعرفالمريض مع الحوار

هي المرض لتشخيص خطوة أهم فإن هذا :وعلى

على إجاباته إلى و المريض إلى الجيد اإلستماعالطبيب أسئلة

إجاباته إلى و المريض إلى الجيد باإلستماع يحدث ماذاالطبيب؟ أسئلة على

في المريض يقع ........حفرة

يسيبه يقع

لوحده، ما يزقوش

يفعل ماذاالطبيب هذه في الحالة؟

ABOUT THE MANAGEMENT OFRHEUMATOID ARTHRITIS

MANAGEMENT OF RA COMPRISES:

PATIENT EDUCATION AND INSTRUCTIONS

MEDICAL TREATMENT

REHABILITATION

SURGICAL TREATMENT SOMETIMES

DON’T UNDERESTIMATE THE POWER OF TALKING TO YOUR PATIENT

PATIENT EDUCATION

MEDICAL TREATMENT

REHABILITATION

NSAIDs AND PHYSIOTHERAPY

Hydroxychloroquine, sulfasalazine, gold

Methotrexate, lefulonamide

Biological Agents

Aim of medical treatment: Induction and maintenance of remission

Severe systemic

illness

Bridge therapy

Intra-articular steroids

Corticosteroids are not part of the medical treatment of RA except in very selected situations as:

Conclusions

THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST:

A CRIPPLING JOINT DISEASE WITH A POSITIVE RF

AND NO TREATMENT

A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION,

BUT

THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL

PRESENTATION

THE MOST IMPORTANT STEP TOWARDS A DIAGNOSIS OF RA IS

A GOOD HISTORY TAKEN BY A GOOD DOCTOR

PRESENTATION

A POSITIVE RF DOESN’T NECESSARILY MEAN RA

AND

A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA

INVESTIGATIONS

PLAIN FILMS IN EARLY RA

MAY BE NORMAL

INVESTIGATIONS

DOCTORS ARE MORE THAN JUST

TABLETS

MANAGEMENT

A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS

PATIENT EDUCATION

MANAGEMENT

CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF

RA EXCEPT IN

VERY SPECIAL SITUATIONS

MANAGEMENT

VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

MANAGEMENT

Thank you