ArtritisReumatoide

• RA has an annual incidence of approximately 0.4 per 1000 in females and 0.2 per 1000 in males.

• A prevalence of 0.4% to 1% is reported in diverse populations worldwide.

• Twin and family studies demonstrate a heritability of

60%; approximately 30% of genetic risk is attributed to the shared epitope encoded on the human

leukocyte antigen molecules.

• Hormonal and reproductive factors contribute to the female excess and parity, breast feeding, and

exogenous hormones are modifiers of risk.

• Smoking is the strongest known environmental risk factor for RA; other lifestyle factors and exposures

such as alcohol, antioxidant intake, and traffic pollution may also play a role.

THE 1987 ACR CRITERIA (TRADITIONAL FORMAT)

1.Morning stiffness

- Morning stiffness in and around the joints,

- Lasting at least 1 hour before maximal improvement

2.Arthritis in three or more joint areas

• Soft tissue swelling or fluid (not bony overgrowth) observed by a

physician presenting simultaneously for at least 6 weeks.

• Possible areas: right or left

proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, metatarsophalangeal joints.

3.Arthritis of hand joints

• Swelling of :

- wrist and - metacarpophalangeal or

- proximal interphalangeal joints

for at least 6 weeks.

4.Symmetric arthritis

• Simultaneous involvement of the same joint areas (defined in 2) on both sides of the body (bilateral

involvement of proximal interphalangeal, metacarpophalangeal, or

metatarsophalangeal joints is acceptable without absolute symmetry) for at least 6 weeks.

5.Rheumatoid nodules

• Subcutaneous nodules over:

- bony prominences,- extensor surfaces, or

- in juxta-articular regions,

observed by a physician.

6.Rheumatoid factor• Detected by a method that is positive in fewer than 5%

of normal controls.

7.Radiographic changes

• Typical of RA on posteroanterior hand and wrist radiographs;

• they must include:- erosions or

- unequivocal bony decalcification localized in or most marked adjacent to the involved joints (OA changes

alone do not qualify).

7.Radiographic changes

A) AR 8 meses. Erosiones en todas MTF

B) AR 5 años. Desorganización articular.

OA: Joint space loss tends to be assymetrical. Subchondral sclerosis,

geodes and osteophytes become more prominent with time.

Please note that a marginal osteophytes can simulate an erosion immediately

above or below.

Knee X-rays in advanced inflammatory arthritis. Note that joint space loss is

homogeneous and symmetrical. There is subchondral osteopenia (as opposed to sclerosis) and erosions can be present .

At least four criteria must be fulfilled for classification of RA;

patients with two clinical diagnoses are not excluded.

(mean duration of symptoms, 7.7 years)1.Morning stiffness Morning stiffness in and around the joints, lasting at least 1 hour before

maximal improvement

2.Arthritis in three or more joint areas Soft tissue swelling or fluid (not bony overgrowth) observed by a physician presenting simultaneously for at least 6 weeks

3.Arthritis of hand joints Swelling of wrist and metacarpophalangeal or proximal interphalangeal joints for at least 6 weeks

4.Symmetric arthritis

Simultaneous involvement of the same joint areas (defined in 2, above) on both sides of the body (bilateral involvement of proximal interphalangeal, metacarpophalangeal, or metatarsophalangeal joints is acceptable without absolute symmetry) for at least 6 weeks

5.Rheumatoid nodules Subcutaneous nodules over bony prominences, extensor surfaces, or in juxta-articular regions, observed by a physician

6.Rheumatoid factor Detected by a method that is positive in fewer than 5% of normal controls

7.Radiographic changesTypical of RA on posteroanterior hand and wrist radiographs; they must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (OA changes alone do not qualify)

Impact on classification of antibodies to citrullinated peptides (ACPA)

• ACPA may be involved in the pathogenesis of the disease, and have been shown to be a more specific marker for RA than RF, particularly for subjects with

early disease.

• In early RA, the specificity of ACPA ranges from 94% to 100% compared with RF, in which the specificity ranges

from 23% to 96%; the sensitivity of RF and ACPA are equivalent in both early and long-duration RA.

• The impact of the addition of ACPA to the existing 1987 ACR criteria to classify early RA, in which 4 of 8 rather than 4 of 7 criteria are required, results in an

increase in the sensitivity for detecting early RA.

Impact on classification of antibodies to citrullinated peptides (ACPA)

1.Morning stiffness Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement

2.Arthritis in three or more joint areas Soft tissue swelling or fluid (not bony overgrowth) observed by a physician presenting simultaneously for at least 6 weeks

3.Arthritis of hand joints Swelling of wrist and metacarpophalangeal or proximal interphalangeal joints for at least 6 weeks

4.Symmetric arthritis

Simultaneous involvement of the same joint areas (defined in 2, above) on both sides of the body (bilateral involvement of proximal interphalangeal, metacarpophalangeal, or metatarsophalangeal joints is acceptable without absolute symmetry) for at least 6 weeks

5.Rheumatoid nodules Subcutaneous nodules over bony prominences, extensor surfaces, or in juxta-articular regions, observed by a physician

6.Rheumatoid factor Detected by a method that is positive in fewer than 5% of normal controls

7.Radiographic changes

Typical of RA on posteroanterior hand and wrist radiographs; they must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (OA changes alone do not qualify)

Clinical features of rheumatoid arthritis

Morning stiffness and symmetric swelling in

the wrists and proximal

interphalangeal and

metacarpophalangeal joints are the typical

features of rheumatoid arthritis (RA).

• Early diagnosis of RA is critical, but many cases of “early arthritis” are not RA.

• Anti-citrullinated peptide antibodies (ACPAs) occur earlier than rheumatoid factor and are more specific

for RA.

The hallmark of RA is

-symmetric synovial proliferation and

-tenderness of multiple joints,

particularly the small joints of the hands and feet.

• Most patients experience joint stiffness or gelling for more than an hour in the morning.

• The blood of approximately 80% of RA patients contains RF, an immunoglobulin binding the Fc

region of the IgG molecule. • Rheumatoid nodules are seen in about 20% of

patients.

80% of RA patients contains RF

• Prognosis and outcome are improved when DMARD therapy is started within a few weeks or months of

disease onset

The immediate institution of

DMARDs results in better outcomes

than when DMARD administration is delayed for even several months

It is well established that erosive damage on radiographs of the

hands and feet develops early in the

course of RA.

• Typical sites of osseous erosion of a rheumatoid wrist shown here include triquetrum, pisiform, scaphoid, and radius. There also are erosions at the ulnar aspect of the distal radius and the distal ulnar styloid process secondary to involvement of the inferior radioulnar

compartment. Diffuse cartilage loss also is evident in the radiocarpal compartment. (Courtesy of Dr. Barbara Weissman.)

Progression of radiographic damage occurs to a lesser degree in patients receiving early therapy than in those

for whom therapy is delayed.•Correlation between radiographic damage and

disability over time.

• Patients have a greater likelihood of attaining remission with early treatment.

• The diagnosis of rheumatoid arthritis be made as soon as possible so that DMARD treatment can be

started without delay.

AR ?

AR ?In osteoarthritis (A.) joint space loss is usually focal or asymmetrical

while in inflammatory arthritis (B.) it tends to be uniform and diffuse

AR ?

Clinical case “Pain in the hands (III)”. Please note that although inspection suggests joint swelling, this can only be proved by palpation.

AR ?

AR ?

In rheumatoid arthritis (A.) periarticular osteopenia is an early radiological feature.

• In osteoarthritis (B.) subchondral bone sclerosis is a typical finding. Also notice the loss of joint space in both conditions.

AR ?

Nodal osteoarthritis of the hands. Discrete bony nodules around PIP (Bouchard nodes) and DIP joints (Heberden nodes).

Nodular deformity of the finger, with deviations of one phalanx over the other in nodal osteoarthritis

AR ?

AR ?

Fusiform swelling around the 2nd and 3rd proximal interphalangeal joints

AR ?

OA nodal

AR ?

AR ?

AR DEFORMIDAD ARTICULAR/DESORGANIZACIÓN

AR ?

AR ?

AR ?

AR ?

HISTORIA

• Commonly, patients will present with

polyarthritis (≥ 5) of the small joints of the hands,

but monoarticular involvement can occur

initially.

• RF and ACPAs have been found in up to half of

patients with RA up to 5 years before their

development of clinical disease.

• Stiffness or gelling in the joints is present on arising, often taking several hours to abate.

• Patients will typically report soft tissue swelling over the knuckles and describe markedly reduced grip

strength.

• Discomfort in the feet is generally most prominent in the metatarsal area.

Profound fatigue often accompanies the joint complaints, and anorexia and mild weight loss may occur.

Typically, patients with RA do not present with rash, fever, headache, visual disturbance, or pleuropericardial

symptoms.

• The pattern of joint involvement in RA is typical in most cases.

- proximal interphalangeal (PIPs), - metacarpophalangeal (MCPs),

- wrists,- elbows,

- shoulders, - hips,

- knees, - ankles, and

- metatarsophalangeal (MTP) joints.

Examination and clinical features of specific joints

• Ability to recognize the manifestations of synovial proliferation.

• Unlike the normal synovial lining, which is only one or two cell layers thick, the RA synovium proliferates

out of control (pannus).

• AIJ

• AIJ. Leg length discrepancy due to chronic arthritis of the left knee

• This proliferating synovium has a “doughy” or “squishy” feel on palpation. This finding is often referred to as “synovitis”; however, the classic

inflammatory signs of heat and redness are usually absent.

• Rheumatoid nodules are quite specific for RA and occur in about 20% of patients, generally those with

more severe disease and high-titer RF.

• They occur over extensor surfaces and joints, at sites of chronic mechanical irritation (elbow, toe, and

heel), and in the subcutaneous tissues of the fingers

• A. Rheumatoid nodules. usually small with a regular surface.

• B. Irregular nodules with white deposits – gouty tophy.

• Synovial cyst of the wrist. The swelling is soft on palpation.

Rheumatoid nodules

The hand in early RA. View of the right hand, showing swelling of the MCP and PIP joints. Swelling of the PIP

joints is typical of RA and associated with morning stiffness, difficulty making a fist, reduced grip strength,

and tenderness of the affected joints

“Four-point” technique for palpating the small joints of the hands.

Palpation of the dorsal and volar aspects of the MCP and PIP joints to detect synovial proliferation.

Art. Metacarpo-Falangica

Flexor tenosynovitis is common and may lead to a “trigger

finger.”

The flexor tendons for the fingers pass

through a pulley near the palmar surface of

the MCP joint.

Flexor tenosynovitis

Signs of late disease with irreversible

damage include “swan-neck” and

“boutonnière” deformities and

subluxation at the MCPs with “ulnar

drift”, often accompanied by atrophy of the

intrinsic muscles of the hand.

A, Swan neck deformity. This common deformity leads to hyperextension of the proximal interphalangeal joints and flexion of the distal interphalangeal joints. B, Boutonnière deformity. This deformity, which is the opposite of swan neck deformity, is marked by flexion of the proximal interphalangeal joints and extension of the distal

interphalangeal joints.  (Courtesy of Iain McInnes, MD.)

• Boutonnière and swan-neck deformities. The boutonnière deformity—PIP flexion and DIP hyperextension—results from relaxation of the central slip, with “buttonholing” of the PIP joint between the lateral bands. The swan-neck deformity—

MCP flexion, PIP hyperextension, and DIP flexion—may be mobile, snapping, or fixed. Its pathogenesis may be related primarily to PIP or MCP involvement. Combinations of MCP and PIP involvement are less frequent

A: patient with early rheumatoid arthritis. There are no joint deformities, but the soft tissue synovial swelling around the third and fifth proximal

interphalangeal (PIP) joints is easily seen.

B: patient with advanced rheumatoid arthritis with severe joint deformities including subluxation at the metacarpophalangeal joints and

swan-neck deformities (hyperextension at the PIP joints).

• Progressive destruction of a metacarpophalangeal joint by rheumatoid arthritis. Shown are sequential radiographs of the same second

metacarpophalangeal joint. A: The joint is normal 1 year prior to the development of rheumatoid arthritis. B: Six months following the onset of

rheumatoid arthritis, there is a bony erosion adjacent to the joint and joint space narrowing. C: After 3 years of disease, diffuse loss of articular

cartilage has led to marked joint space narrowing.

• The thumb can be affected by several deformities. Arguably the most common has been described as the flail interphalangeal (IP) joint, in which case the

patient loses the ability to flex that joint. • This results in significant functional impairment due

to loss of pinch strength, whereby the patient pinches the index finger against the proximal

phalanx.

• At the wrist, synovial proliferation around the ulnar styloid occurs; and as the disease progresses, laxity of the radioulnar ligament gives rise to the “piano

key” sign, as the ulnar styloid moves up and down in response to dorsal pressure from the examiner's

thumb.

• Carpal tunnel syndrome from compression of the median nerve is quite common and often responds

to treatment of the disease.

Articulación Radio-Carpiana

• Subluxation of the wrist can result in severe disease.• Extensor tenosynovitis of the extensor carpi ulnaris

and extensor digitorum communis sheaths in the dorsal wrist produces a characteristic pattern that is

virtually unique to RA

Tenosynovial swelling from tenosynovitis —the “tuck” sign. Tenosynovial swelling overlies the metacarpals of the right hand. Bulging becomes accentuated with full extension of all the fingers of the hand. Persistent tenosynovitis over the dorsal wrist may

lead to extensor tendon erosion and rupture, particularly of the tendons of the fourth and fifth fingers.

• The tubular swelling of the common extensor tendon sheath ends abruptly just distal to the wrist joint. This often obscures swelling at the

dorsal wrist (radiocarpal) joint itself. Damage from the chronic tensosynovial inflammation and friction where the extensor tendons of the third, fourth, and fifth fingers cross the jagged and

eroded ulnar styloid can lead to tendon rupture with inability to actively extend those fingers.

Subluxation of the wrist in severe disease, associated with extensor tenosynovitis and extensor tendon rupture.

• Three characteristic findings occur at the

elbow. - Synovitis may be palpated between the lateral epicondyle and

the olecranon prominence.

- The radiohumeral joint is just distal to the lateral epicondyle.

Swelling of the olecranon bursa often occurs in more severe disease and tends

to be bilateral. In fact, bilateral olecranon bursal swelling occurs only

in RA, gout, and pseudogout.

The olecranon and extensor surface of the proximal ulna are very

common sites for rheumatoid nodules.

Shoulder involvement typically produces significant limitation of motion in all planes.

A visible effusion of the glenohumeral joint is unusual but can produce a “shoulder pad” sign.

On examination, the patient will elevate the

scapula to improve range of motion for

abduction and elevation.

Shoulder pain is often referred to the

proximal deltoid region.

Evidence of impingement of the supraspinatus and biceps tendons is

often present.

Owing to ongoing synovitis, rupture (either partial or complete) of the

rotator cuff group of muscles may

occur.

Tenderness and swelling may also

be seen at the sternoclavicular

joint.

AR: HOMBRO

Abnormalities of the shoulder in rheumatoid arthritis. The Grashey posterior oblique view

of a shoulder shows severe glenohumeral joint space narrowing

with a marginal erosion and cystic change of

the humeral head adjacent to the greater

tuberosity (lower arrow). Elevation of the

humeral head with respect to the glenoid

indicates chronic rotator cuff tear. There also is tapering of the

distal end of the clavicle and widening

of the acromioclavicular joint

(upper arrow). (Courtesy of Dr.

Barbara Weissman.)

• Spine involvement in RA is mostly limited to the cervical spine, particularly the upper portion.

• On examination, one notices decreased range of motion in all planes.

• The most critical involvement occurs at the atlantoaxial joint, where the ring of C1 pivots on the odontoid peg of C2. The transverse ligament of the

axis courses around the posterior portion of the odontoid, preventing subluxation of C1 on C2

• Tenosynovitis here can decrease the space available for the upper cervical cord, as it passes through the

bony spinal canal posterior to the odontoid. This can also lead to laxity of the transverse ligament or

erosion of the odontoid.

This radiograph of the rheumatoid cervical spine in flexion demonstrates atlantoaxial subluxation as

the arch of C1 slides forward (arrows).

Laxity of the transverse ligament or erosion of the

odontoid, in which case the ring of C1 can move forward on neck flexion (atlantoaxial subluxation), reducing the

diameter of the spinal canal and compressing the upper

cervical cord.

Cranial settling describes the

caudal migration of the cranium on the spinal column,

resulting in movement of the odontoid into the foramen magnum,

where it compresses vital

structures.Cranial settling occurs when the cranium migrates caudally onto the odontoid, which impinges on the brain stem above the foramen magnum. The odontoid should not extend much above a line drawn

between the white and black arrows.

Subaxial subluxation represents unstable

movement of one vertebral

body on another

below C1-C2. Vertebral

artery compromise

can also occur as a result of

these structural defects.

Rheumatoid arthritis of the cervical spine. T2-weighted

sagittal image shows low signal periodontoid pannus (P).

Odontoid process appears irregular secondary to erosions

(arrow). The atlantodental distance shows mild widening (solid line). There

also is vertical subluxation without signs of cord

compression. Anterior subarachnoid space is

compromised by disk protrusions at multiple levels. Erosions

(arrowheads) are seen at the vertebral end plates at the C6-C7 level. (Courtesy of Dr. Barbara

Weissman.)

• Rheumatoid arthritis of the cervical spine. A, Lateral radiograph in flexion shows severe anterior atlantoaxial subluxation with a wide anterior atlantodental interval

(asterisks) and decreased posterior atlantodental interval (arrow). B, Almost complete reduction of subluxation is noted on the lateral view in extension. There

also is subaxial subluxation at the level of C4-C5 (arrowheads) with erosive changes in various facet joints. O, odontoid. (Courtesy of Dr. Barbara Weissman.)

• Cervical spine involvement/clinical manifestations:- headache, - neck pain,- sensation that the head might fall off, - paresthesias, - weakness,- transient ischemic attack,- bowel and bladder sphincter impairment.

• The development of any of these symptoms in a patient with severe RA calls for immediate

neurologic examination.

• The hip is frequently affected in RA, and progressive disease can lead to severe secondary osteoarthritis requiring total joint replacement. Pain from the hip

joint itself is experienced in the groin and medial thigh, sometimes radiating to the buttock.

• Pain over the greater trochanter, which most patients refer to as the “hip,” is more likely due to bursitis.

Patrick's test (also known by the acronym

FABER for flexion-abduction-external

rotation) puts the hip through passive motion in all major planes and produces groin pain in

the presence of true hip disorders.

Sudden development of hip pain suggests avascular necrosis or fracture in patients taking long-term

corticosteroids.

• Rheumatoid involvement of the knee joints is easy to detect by physical examination and is often a good

indicator of disease activity.

Swelling of the left knee: loss of bone contours and suprapatellar swelling. Patients usually

keep the knee in flexion

• Distention of the posterior compartment

of the knee capsule

produces a tense Baker's

cyst in the popliteal region.

Baker's cyst in the popliteal region.

• Baker's cyst in the popliteal region. Rupture of such a popliteal cyst can produce swelling, heat, and pain in

the posterior calf, resembling a deep venous thrombosis. A hemorrhagic “crescent” sign below

the malleoli may result.

Acute synovial rupture. A 51-year-old man with RA of 3 years’ duration developed a right knee effusion after an evening of square dancing. Two days later he noted progressive pain and swelling of the right calf. (a) Six days later there was bluish

discoloration of both sides of the ankle. (b) A few weeks later, after more dancing, he noted posterior thigh pain and swelling that soon became associated with purple

discoloration of his right posterior thigh. 

• Progressive synovitis can lead to loss of articular cartilage, secondary osteoarthritis, and the need for

total knee arthroplasty.

32

REEMPLAZO PROTESICO

Examining the synovial fluid can be very helpful in

distinguishing between

persistent disease activity and mechanical

damage.

In chronic disease, quadriceps atrophy and flexion contracture are common.

Muscle atrophy of the right thigh in association with ipsilateral knee arthritis.

The ankle: the capsule of the tibiotalar joint

distends anteriorly, effacing the normal

contour of the tibialis anterior

tendon.

The joint line itself can be palpated between that tendon and the medial

malleolus, where synovial proliferation can be

identified.

Progressive joint damage to the tibiotalar, subtalar, and talonavicular joints can result in ankle and midfoot pronation and loss of the transverse

arch, producing mechanical symptoms that can be quite challenging to manage.

Rheumatoid arthritis of the ankle. There is diffuse loss of cartilage space with erosions of the fibula (arrows).

The scalloping along the medial border of the distal fibula is designated the fibular notch sign and is a characteristic finding in rheumatoid arthritis. The

hindfoot is in valgus alignment

• Tendinitis of the posterior tibialis develops posterior and medial to the medial malleolus. In the same

area, the posterior tibial nerve can be compressed in the tarsal tunnel, leading to paresthesias on the sole

of the foot.

Articulacón tibio-atragalina

• Fig. 1. Bilateral swelling of the ankle joints, retrocalcaneal bursae, and in the area of the synovial sheaths of the posterior tibialis, flexor hallucis longus, and peroneal longus and brevis tendons and in the area of extensor tendons in an HLA-B27 10-year-old boy having neither axial symptoms nor radiographic sacroliitis, (A) posterior view and (B) lateral view. Reprinted from Burgos-Vargas R, Pacheco-Tena C, Vázquez-Mellado J. Juvenile-onset spondyloarthropathies. Rheum Dis Clin North Am 1997;23:569–98; with permission.

• The forefoot: tenderness to palpation of the individual MTP joint or to squeezing the forefoot.

• Swelling can be seen in the dorsum of the foot just proximal to the toes.

• As disease progresses, the metatarsals sublux on the plantar aspect of the proximal phalanges, displacing

the soft tissue fat pads that normally underlie the metatarsal heads.

• Furthermore, the forefoot broadens and the transverse arch of forefoot disappears, so that

the patient's metatarsal heads are now directly bearing the weight of the entire body.

Calluses develop under the

metatarsal heads; and in advanced

cases of RA, ulcerations occur at

this location. Hammertoes

(resembling piano key hammers) develop from

increased tension on the flexor

tendons from the MTP subluxation.

Cabeza de los Metartasianos

Diagnosis

• Rheumatoid arthritis is a clinical diagnosis for which there is no one single physical finding or laboratory

test that is pathognomonic.

• As a practical matter, a patient older than the age of 18 who has symmetric joint pain and swelling in the hands and feet and morning stiffness is likely to have RA, especially if the RF and/or the ACPA findings are

positive.

• Some data suggest that definitive treatment should be administered within 3 months of the onset of

disease.

• Therein lies the advantage for the 2010 ACR/EULAR

Survival of patients with extra-articular manifestations of rheumatoid arthritis

Nodules

Fig. 83.2  Gross anatomic specimen of a rheumatoid nodule. The yellow tissue is caused by fibrinoid necrosis

  Rheumatoid nodules in a patient with long-standing rheumatoid arthritis treated with low-dose weekly methotrexate

Fig. 83.6 Pleural effusion and rheumatoid nodule in rheumatoid arthritis. Changes associated with diffuse interstitial fibrosis are also present. 

• The most common radiographic finding is bilateral basilar interstitial abnormalities, which are often asymmetric. Initially, these may appear as patchy

alveolar infiltrates; with progressive disease a more reticulonodular pattern is seen.

• High-resolution computed tomography (CT) and open lung biopsy are considered the gold standard methods for diagnosing interstitial lung disease.

Ocular Involvement

EPIESCLERITIS ESCLEROMALACIA

Rheumatoid Vasculitis

• Systemic vasculitis in RA is uncommon and often occurs in rheumatoid patients who have long-standing disease of more than 10 years.

• Rheumatoid synovitis may not be active when the features of the systemic vasculitis are present.

• Small vessel vasculitis commonly involves the skin and causes nailfold infarcts, digital gangrene, and leg ulcers.

Nailfold infarcts in a patient with rheumatoid arthritis

Digital tip and proximal infarcts in a patient with rheumatoid vasculitis. 

• GRACIAS