Rheumatoid arthritis (RA), an autoimmune disease, is an inflammatory, symmetric form of arthritis that causes varying degrees of joint destruction, disability, deformity, and premature death. Some patients are genetically susceptible to RA, while others may have hormonal or environmental contributing factors. The chief target of inflammation is the synovial lining of diarthrodial joints. Early changes in the synovial membrane are observed in the capillaries. The synovial membrane encounters hyperplastic thickening due to the proliferation of fibroblasts and new blood vessel formation. Clinical manifestations of RA occur insidiously over several weeks to months, but sometimes, patients can have acute symptoms. Initial symptoms include generalized weakness, fatigue, weight loss, aching, and stiffness. Symptoms then become more localized with swollen, painful joints. Patients with RA usually have pain that is worse in the morning that lasts at least 30 minutes or all morning. Patients with osteoarthritis may also experience morning pain, but the pain typically does not last as long as it does in RA. Initially, the most commonly affected joints include the small joints of the hands, wrists, and small joints of the feet. Joint involvement will be bilateral and symmetric in RA and may also affect the knees, hips, shoulders, ankles, and cervical spine. On physical examination, the inflamed joint may feel tender and warm. The synovial membrane will feel boggy and thick on palpation. The skin over the joint may have a ruddy color and appear shiny and thin. A diagnosis of RA can be made based on history and physical examination. RA can affect many organs, including the heart and spleen. A baseline laboratory panel is recommended on initial diagnosis and periodically includes complete blood count, erythrocyte sedimentation rate, C-reactive protein, serum creatinine, liver function tests, urinalysis , rheumatoid factor, and anti-cyclic citrullinated peptide antibodies. Normocytic, normochromic anemia is common in patients with RA. Antirheumatic drugs can be nephrotoxic and hepatotoxic, which is why baseline kidney and liver function tests are necessary. Ultrasound and MRI can both be used to confirm an RA diagnosis. A hallmark sign of RA is bone marrow edema. Synovial fluid aspiration can also be used to confirm a diagnosis. Normally, synovial fluid is clear and viscous. In RA, the synovial fluid has poor viscosity and a high WBC count. Treatment may include a regimen of NSAIDs, glucocorticoids, and antirheumatic drugs. A referral to a rheumatologist is often indicated.
Pain that is worse after activity (A), at night (B), or on palpation (D) is not specific to rheumatoid arthritis.
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