Rheumatoid Arthritis

RA is an autoimmune inflammatory disease of the overall connective tissue predominantly synovium. It is the most common chronic inflammatory rheumatism. The female is strong (sex ratio 1/4). The peak frequency is premenopausal.

1- Clinic:

– Adverse distal joint, bilateral and symmetrical (arthritis)

– The most frequently affected joints: wrists, hands (metacarpophalangeal, proximal interphalangeal), the front feet, knees and sometimes métatarsophalagiennes The distal interphalangeal (DIP) are met.

– Tenosynovitis flexors (swelling of the palms, crepitus in palmar flexion, sd carpal tunnel)

– Insidious and progressive beginning. Must be advanced for more than 6 weeks. Chronic if> 3 months

– Usually the thoracolumbar spine and sacroiliac are respected

– Gradually joint and ligament injuries lead to permanent deformation

– Deformation of the hand posterior subluxation of the ulnar head with mobility piano key (threatening the extensor tendons); gooseneck finger (the most common and most annoying); deviation of the fingers Ulnar wind

– There is a risk of tendon rupture (extensors)

– Infringement of the foot (90%): hallux valgus deformity of the big toe and claw of the other toes (foot triangular characteristic)

– The TMJ arthritis (TMJ) are highly suggestive of PR

– Involvement of the cervical spine is common (posterior neck pain). C1-C2 subluxation is typical, it evolves into an anterior dislocation. But neurological complications are rare (occipital neuralgia, spinal cord compression).

2- Biology and Histology:

– VS biological inflammatory syndrome with high leukocytosis normal or high (25%). Normal VS (10%) does not eliminate the diagnosis. A hyperthrombocytose is found in 20% of cases.

– Rheumatoid factor: self-Ac IgG IgM (Fc). They are not specific to the PR. Often negative in the first months of evolution. Latex Test (1 / 80th); Waaler-Rose (1/64 °). They may sensitive (80% after 2 years) and low specificity. It can be detected in other connective (lupus syndrome Sjogren) or chronic infectious diseases (endocarditis Osler, hepatitis C, Kala-azars)

– Anti-keratins Ac (antistratum corneum or anti-fillagrin) are highly specific (99%) but inconstant (sensitivity 44%)

– Other self-Ac Ac antiperinuclear (sensitive and specific enough); antinuclear factor (FAN); anti-RA ac 33

– HLA typing: HLA DR4 is present in 60% of RA. It has a prognostic value

– Synovial fluid: inflammatory types; the complement assay (which is low) and rheumatoid factor has no interest. The ragocytes are PNN with cytoplasmic inclusions). A variegated form lymphocyte dominance can be met.

– Biopsy of synovial: only useful in atypical forms (mono-arthritis). Synovitis is nonspecific and is characterized by hypertrophy of synovial villi and multiplication of fringes. Hyperplasia of synovial villi. The presence of rheumatoid nodules intrasynoviaux is exceptional.

3- Radiological signs:

– Often absent at the beginning (is visible only 1 or 2 years of evolution)

– Then fusiform thickening of soft tissue periarticular

– And increased radiation transparency of the epiphysis (demineralization or osteoporosis band)

– More late (but more evocative) -> periarticular erosions (blurred or notched) to capsular synovial insertion (4th, 5th metatarsal, ulnar styloid, scaphoid)

– The subchondral geodes are sometimes early (first sign to appear)

– Finally, the overall narrowing of the joint space translates cartilage destruction

– Bone condensations and ostéophytoses are absent (except stage arthropathy late sequelae)

– F specific radiological elms

* Rheumatoid carpite: first causes demineralization, pinching interlining, geodes. Then carpite amalgamating with osteolysis and condensation.

* Hand in spyglass (shriveled fingers): very advanced form with osteolysis of the metacarpals and phalanges.

4- Extra-articular manifestation:

– Rheumatoid nodules (15%), subcutaneous (swelling firm and painless to the hands, Achilles tendon …). The visceral nodules are rare.

– Vasculitis: Raynaud’s syndrome; necrotizing vasculitis; purpura, ulcers; mononeuritis

– Felty’s syndrome (splenomegaly leukoneutropenia +);

– Leukemia

– Caplan syndrome: pneumoconiosis (silicosis with intrapulmonary rheumatoid nodules)

– Interstitial diffuse (20%)

– Bronchiectasis (DDB) are common in CT (30%)

– Violations of the serous (pleural, pericardial effusion)

– Sjögren’s syndrome (15%)

– Secondary Amyloidosis AA (5%) late complications

5- Background processing:

– The basic treatment should be started as soon as possible; it blocks the disease; verify the efficacy after 3 months; if no efficiency must increase the dose, change treatment or to an association

– Methotrexate: against-indicated in pregnancy, infection or chronic liver disease (hepatotoxic). Regular monitoring of albuminuria and creatinine and the transaminasémie (risk of cytolytic hepatitis). effective contraception.

– Hydroxychloroquine (Plaquenil®): synthetic antimalarial; risk of damage to the retina (electroretinogram systematic the first year and examination of color vision every 3 months). Is always used in combination

– Sulfasalazine (Salazopyrine®) monitoring counts liver function tests and platelet counts

– Gold salts (Allochrysine®) control proteinuria and platelet count before each injection

– D-penicillamine (thiol compounds)

– Anti-TNF: these side effects are serious infections, an induced lupus, an abortion

– The crenotherapy is against-indicated thrust

Biotherapy is effective

Pejorative factors:

* Acute onset polyarticular

* Extra-articular Achievement

* Early radiographic bone erosion

* VS and very high CRP

* EN early (<6 months) and high

* HLA-DR ß1 04

* Poor response to DMARD therapy

* High socioeconomic status

+ Diagnostic ACR criteria: arthritis affecting at least 3 joints (PIP, MCP, MTP, wrist, knee, ankle or balanced) lasting for at least 6 weeks, morning stiffness of more than 1 hour (> 6 weeks ), rheumatoid factor, rheumatoid nodules and radiographic changes (osteoporosis band erosions). 4 positive signs are sufficient for diagnosis

Pannus -> synovial proliferation