RHEUMATOID ARTHRITIS

Case
A woman 26 years old come with pain in
her joint, especially in her fingers, the pain
is continously. There are stiffness in the
morning during 1 hour and fever since 2
days ago.
Physical examination : there are
tenderness and redness in MCP and PIP
Laboratory findings :
LED I/II : 75 / 80
Rheumatoid factor : positive
 Differential Diagnosis
Characteris Rheumatoid
Osteoarthritis Gout Arthritis
tic Arthritis
Pain & swelling on
major weight A type of arthritis
Inflammation in bearing joints, that causes
multiple joints, stiffness, inflammation,
Symptoms
morning stiffness > crepitation, usually in one
30 mins tenderness, joint, that begins
morning stiffness suddenly
< 30 mins
Gender Female > Male Female > Male Male > Female
Men : >35 years
Age 20 - 50 years old > 50 years old Women : after
menopause
Weight bearing
Small joints (PIP, 1st Meta Tarsal
Location joints (genu, hip,
MCP, MTP) Phalangeal Joints
vertebra)
Symmetry and
Symmetrical Asymmetry Asymmetry
bilateral
Pathological
Autoimmune Degeneration Hyperuricemia
 Based on Case
Rheumatoid Gout
Keyword Osteoarthritis
Arthritis Arthritis
Woman Yes Yes No
Pain in fingers joint Yes Yes Yes
Stiffness in the
morning during 1 Yes No No
hour
Fever since 2 days
Yes No Yes
ago
Tenderness and
redness in PIP and Yes No No
MCP

From the table above, current diagnosis is Rheumatoid Arthritis

 Additional Anamnesis
Onset of disease : weeks until
months
Pain of the joint usually bilateral
History of past illness
Familiy history
Medication history
 Additional Physical
Examination
Affected joint show inflammation
with swelling, tenderness, warmth,
and decreased range of motion
(ROM).
Atrophy of the interosseous muscle
of the hands is a typical early finding
Joint and tendon destruction may
lead to deformities such as ulnar
deviation.
 Additional Examination
C-Reactive Protein : Increase > 0,7 picogram/ml
Leukosit : maybe increase (acute phase)
Tromobosit : Usually increase (acute phase)
X-ray radiography : there are osteopenia or destruction
of joint
MRI : we can see the destruction of the joint early than
x-ray, and we can see the joint structure more clearly.
Anticyclic citrullinated peptide antibody (anti-CCP) :
same with rheumatoid factor but anti-CCP more spesific
Anti-RA33 : we use this examination if RF or anti-CCP
negatif
 Clinical Manifestation of
Rheumatoid Arthritis
Symmetrical joint swelling (MCP, PIP,
MTP)
Tenderness to palpation
Pain
Motion impairment
Morning stiffness (> 1 hours)
Malaise, fatigue, myalgia,weight loss,
fever
 Clinical Manifestation
Articular manifestation :
inflammation of the joint capsule
(swelling, redness, warm) mostly in
MCP and PIP
Extraarticular manifestation : nodul
rematoid, vasculitis,
keratoconjunctivitis sicca
Deformity (swan-neck, boutonniere,
ulnar deviation,
 Pathophysiology
Rheumatoid Arthritis is caused by an autoimmune
reaction with unknown of exact cause, some
contributing factors (hereditary or envorimental)
can trigger this reaction.
These autoimmune reactions leads into the release
of inflammatory mediators and cytokines, which
cause a chronic inflammation of the synovial tissue
lining the joint capsule and resulting the
proliferation of tissue and forming a Pannus, which
invade cartilage and bone surface and causing
erosion which leads to joint destruction.
 Therapy
Pharmacological therapy
NSAIDs anti inflammation drugs and
analgetic (Meloxicam 7,5 mg/day or
Piroxicam 20 mg/day)
DMARD to slow or prevent structural
proggression of RA, good for acute
onset of RA (Methotrexate 10
mg/week or Sulfasalazine 2x500
mg/day)
 Therapy
Non Pharmacological therapy
Education about the disease and therapy
Cod liver oil suplement
Cold/hot therapy to reduce pain
Consult for surgery if there is:
Severe pain (related to extensive joint
destruction)
Limitation of movement or function
Tendon rupture