Rheumatoid arthritis
Amalia Raptopoulou
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is a type of chronic autoimmune arthritis that can affect people of any age, race or background. RA is not caused by injury or destruction of the joint, as in the case of osteoarthritis, which is the most frequent arthritis of older people.
The presence of autoantibodies leads to inflammation of the joints, tendons, synovial membranes that surround the joints. Sometimes other organs can be affected (e.g. the lungs, eyes, etc).
How does it appear?
The most common symptoms include joints pain, swelling, stiffness (e.g. difficulty in opening and closing fingers easily), especially in the morning or after prolonged immobility. The joints may also be warm, or even slightly reddened. Sometimes patients complain for a feverishness, severe stiffness or weakness. The symptoms are usually persistent and may “migrate” (from one joint to another) or cumulative (starting in one joint and spreading to others that also became painful and inflamed).
Apart from the cervical spine and distal interphalangeal (DIP) joints, all the small and large joints of the upper and lower limbs can be affected. In some large joints, such as the knee, patients can collect large amount of fluid, and this joint would became extremely painful, hot and swollen.
If a long period of time goes by without treatment, the joints slowly begin to degenerate, which is usually irreversible and leads to permanent deformities. Therefore, in order to maintain the patients’ quality of life, early diagnosis and the prompt treatment initiation are essential. Regular follow-up is also important, to control the disease activity.
How is the diagnosis made?
The diagnosis is made by a rheumatologist, who takes into account the clinical image (the symptoms and the findings from the clinical examination) as well as blood test and imaging findings (X-ray, Ultrasound or MRI). Blood tests, such as “rheumatoid factor (RF)”, or other autoantibodies (e.g. Anti-CCP) are not sufficient to make the diagnosis. That means that some people, in a random check up, may have positive both or one of these tests, but do not have RA, while some others with disease symptoms have these tests negative (seronegative RA).
Increased inflammation markers (BSR, CRP), sometimes accompanied by anemia of chronic disease are also helpful additional markers for diagnosis. The aforementioned tests, along with the detailed personal history and thorough clinical examination with control of all joints, is the “key” for the early and correct diagnosis of the disease, as well as for its differential diagnosis from other inflammatory or non-inflammatory arthritis, such as crystal induced arthropathies (e.g. gout or pseudogout), collagen diseases (such as Systemic Lupus Erythematosus), spondyloarthritis, psoriatic arthritis, osteoarthritis, etc.
What is the role of musculoskeletal ultrasound in the diagnosis and monitoring of RA?
Lately, the application of the ultrasound (US) method for musculoskeletal imaging has become an extremely useful tool in diagnosis of RA and not only. It has changed the daily clinical practice in rheumatology, with multiple and useful applications. It shows greater sensitivity than the clinical examination for diagnosing of arthritis, tendinitis, enthesopathy, etc. It also shows much greater reliability than plain x-rays for the imaging of bone erosions in inflammatory diseases. In addition, ultrasound-guided drug injections seem to have better results than classic “blind” punctures.
Particularly important advantages of US, over the other imaging techniques, are the low cost, the possibility for immediate application during the clinical examination, as well as the clinical correlation of the imaging findings, at the moment of patients’ attendance. The early diagnosis of rheumatoid arthritis, when it is still in an early stage, the determination of the disease severity, as well as the close monitoring of the response to the treatment is absolutely necessary. For these reasons the application of the US has become a particularly useful application in inflammatory arthritis.
Imaging of:
- the fluid collection in the joints,
- synovitis (inflammation of the synovial membrane that surrounds the joint),
- erosions as well as
- accompanying findings of arthritis (tenosynovitis, bursitis, etc.) are achieved with US with great precision and sensitivity. Specific US findings can also distinguish rheumatoid arthritis from other types of inflammatory arthritis. The power Doppler signal (imaging of the increased blood flow) can also be used to monitor response to treatment.
Is there a treatment for rheumatoid arthritis?
Yes, today thanks to the advances in Rheumatology there are great therapeutic possibilities for the treatment of rheumatic diseases. The main goal of the treatment is the disease remission, which is achieved by administration of anti-rheumatic drugs. They are called “disease-modifying drugs” and can be either first-line (“synthetic”) such as Methotrexate or Leflunomide, or second-line anti-rheumatic drugs (“biological”), that are products of biotechnology. Biological drugs are usually used when conventional drugs fail. The use of cortisone is indicated in either the initial stage of RA or temporarily in the outbreaks of the disease.
What is the prognosis of the disease?
The therapeutic goals include the relief of pain and other symptoms, the improvement of joint functionality, the prevention of joint destruction and the prevention of vital organs damages. They guide to the improvement of the patients quality of life in general.
With early diagnosis and the prompt administration of appropriate treatment to induce remission, the patient can continue his life normally. However, the close and effective clinical and ultrasound monitoring by a rheumatologist is absolutely necessary in order to achieve and maintain the disease remission.