Rheumatoid Arthritis Imaging

Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune multisystemic
inflammatory disease which affects many organs but predominantly
attacks the synovial tissues and joints.
Epidemiology
The overall prevalence is 0.5-1% and the disease is 2-3 times more
common in women.
Pathology

Aetiology is unknown but is probably multifactorial. It is generally

considered that a genetic predisposition (HLA-DR B1 which is the most
common allele of HLA-DR4 involved in RA) and an environmental
trigger (Epstein-Barr virus postulated as a possible antigen, but not
proven) lead to an autoimmune response that is directed against
synovial structures and other organs.
Activation and accumulation of T CD4 cells in the synovium starts a cascade of
inflammatory responses which result in:
• activation of the macrophages and synovial cells and production of cytokines
such as IL4 and TNF, which in turn cause proliferation of the synovial cells and
increase production of destructive enzymes such as elastase and collagenase by
macrophages
• activating B cell lymphocytes to produce various antibodies including rheumatoid
factor (RF-IgM antibodies against Fc portion of the IgG) which makes immune
complexes that deposit in different tissues and contribute to further injury
• directly activate endothelial cells via increased production of VCAM1, which
increases the adhesion and accumulation of inflammatory cells
• producing RANKL which in turn activate osteoclasts causing subchondral bone
destruction
The inflammatory response leads to pannus formation. Pannus is an
oedematous thickened hyperplastic synovium infiltrated by
lymphocytes T and B, plasmocytes, macrophages and osteoclasts.
Pannus will gradually erode bare areas initially, followed by the
articular cartilage. It causes a fibrous ankylosis which eventually
ossifies.
Diagnostic criteria
• Diagnosis is based on a combination of clinical, radiographic, and
serological criteria. The 2010 ACR - EULAR classification criteria for
Rheumatoid Arthritis has a maximal score of 10 and requires a score
of >6 for a diagnosis of RA to be made:
Joint involvement
0: large joint
1: 2-10 large joints
2: 1-3 small joints (with or without involvement of large joints)
3: 4-10 small joints (with or without involvement of large joints)
5: >10 joints (at least 1 small joint)
Serology
0: negative RF and negative anti-CCP
2: low-positive RF or low-positive anti-CCP
3: high-positive RF or high-positive anti-CCP
Acute phase reactants
0: normal CRP and normal ESR
1: abnormal CRP and abnormal ESR
Duration of symptoms
0: <6 weeks
1: >6 weeks
Markers
There are several serological markers for rheumatoid arthritis:
• rheumatoid factor (RF): is an IgM antibody against FC portion of the
IgG antibodies, and is a traditional marker but is
nonspecific; associated with several autoimmune and chronic
infectious diseases
• anti-cyclic citrullinated peptide (anti-CCP)/anti-citruillated plasma
antibody (ACPA): it is more than 80% sensitive and more than 95%
specific
• elevated ESR or C-reactive protein
• Yellow arrows indicate Boutonierre deformity
• Red arrow indicates hitch-hiker thumb deformity
• Red circle indicates key area of affection of the intercarpal spaces
Treatment and prognosis
Treatment of RA is aimed at improving the symptoms and slowing
disease progression. Therapy is with a combination of corticosteroids,
non-steroidal anti-inflammatory drugs (NSAIDs), disease modifying
anti-rheumatic drugs (DMARDs), and TNF antagonists (e.g.
etanercept) The anti-TNF treatments and variants of, which suppress
the immune system, are known collectively as biological therapies.
The disease carries a significant burden of disability. There is also a
reduction in life expectancy, with excess mortality usually related to its
non-articular manifestations.