Rheumatoid arthritis Diagnosis

  • Diagnosis

    Rheumatoid arthritis (often shortened to "RA") is a disease in which the immune system attacks the body's own tissues. The joints of the hands, wrists, ankles, knees, and feet are usually the most seriously affected, but the severity and pattern of the disease varies substantially from one person to another Figure 01. Common early symptoms of rheumatoid arthritis include pain, swelling, and stiffness of the joints. Later, symptoms may include joint deformity and loss of joint movement. The pain and swelling may disappear at times as if the disease has been cured (a period called remission), only to flare up again later.

    Click to enlarge: Common pain sites of rheumatoid arthritis

    Figure 01. Common pain sites of rheumatoid arthritis

    Without early treatment, the damage that rheumatoid arthritis causes can become worse over time. The disease has the potential to damage the joint's tissues and the bones. In rheumatoid arthritis, continuous inflammation in the spaces between the joint gradually damage the fibrous connective tissue that holds the skeleton together at the joints (cartilage), narrowing the joint space and eventually eroding bone. Under normal circumstances, inflammation is a product of the body's immune system, which fights off invaders and infections, and heals injuries. Inflammation usually dies down once the body has gotten rid of the problem. But in rheumatoid arthritis, the body's immune system continues to attack the joints, which leads to persistent inflammation, for reasons that are not yet understood. This process gradually ruins cartilage and erodes the bones.

    Rheumatoid arthritis can strike people as early as age 30, but it most often occurs in people between the ages of 40 and 60. Prior to 60 years of age, it affects women three times as often as it does men. After age 60, there is an equal frequency of men and women.

    There are several different types of rheumatoid arthritis. Your diagnosis will be based upon your symptoms and the results of tests and x-rays.

    The diagnosis of RA is a clinical one, supported by laboratory tests and x-rays. The various types of rheumatoid arthritis are differentiated by the symptoms they produce and the presence or absence of a certain protein in the bloodstream. This protein, known as an autoantibody, is called the rheumatoid factor (RF), and is produced as a result of the body attacking its own immune system. The presence or the absence of RF does not indicate whether or not you actually have rheumatoid arthritis. It can, however, indicate what type of the disease you have.

    About 80% of people with rheumatoid arthritis have a positive test for rheumatoid factor. This form of rheumatoid arthritis is called rheumatoid factor—positive (or seropositive) rheumatoid arthritis.

    In contrast, some people with rheumatoid arthritis consistently have a negative test for rheumatoid factor. This form of rheumatoid arthritis is called rheumatoid factor—negative (or seronegative) rheumatoid arthritis. It tends to be milder than the seropositive type.

    Rheumatoid factor status can fluctuate in some people with rheumatoid arthritis.

    A team of health care providers often manages rheumatoid arthritis. A rheumatologist—a doctor who specializes in musculoskeletal conditions—most commonly treats rheumatoid arthritis. However, a primary care doctor plays an important role in monitoring the effectiveness of treatment, treating other medical conditions, and addressing the psychological and social effects of rheumatoid arthritis. Who you see will depend on the severity of your rheumatoid arthritis. A physical therapist will help you to rehabilitate any loss of movement you may experience. An occupational therapist will help you to improve and recover your ability to perform tasks in your daily living and working environments. Your team of health care professionals may also include a surgeon and a psychiatrist or psychologist to help you with the emotional stress of the condition.

    Most people with rheumatoid arthritis can still participate in family, occupational, and social activities. Aggressive treatment during the first few months after diagnosis will keep your condition under control. While there may be some days where your pain and discomfort may prevent you from participating in your regular activities, there is a good chance that you could enjoy long periods of disease control.

    Rheumatoid arthritis is thought to result from a combination of genetic susceptibility and exposure to some “trigger.” The specific trigger for rheumatoid arthritis has not been identified at this time. Researchers are still looking for the factor that suddenly initiates rheumatoid arthritis in susceptible people. They suspect that some infectious agent, perhaps a bacterium or virus, triggers the inappropriate immune reaction.

    If you have rheumatoid arthritis in your family, you may be more susceptible to the disease yourself.

    Pain in the joints is the hallmark of early rheumatoid arthritis Table 01. The inflammation of rheumatoid arthritis causes joint pain, swelling, warmth, redness, and stiffness. Movement typically worsens the joint pain. Because many joints of the body are affected, rheumatoid arthritis is often associated with a sensation of generalized stiffness, especially in the morning and after inactivity. The stiffness lasts longer than 30 minutes, which is one factor that makes it different from another common type of arthritis called osteoarthritis.

    Table 1.   Symptoms of Rheumatoid Arthritis

    Pain, redness, warmth, swelling, and/or stiffness of the joints
    Worsening of joint pain with movement
    Overall stiffness in the morning and after inactivity
    Fatigue
    Generally feeling unwell (malaise, flu-like symptoms)
    Loss of appetite
    Firm, painless growths under the skin near the joints

    In contrast to some other types of arthritis, rheumatoid arthritis affects many joints throughout the body. The joints of the hands, wrists, ankles, knees, and feet are usually most severely affected. The disease usually affects the same joints on the right and left sides of the body (symmetrical).

    Several other conditions share symptoms with rheumatoid arthritis. The symptoms of rheumatoid arthritis may overlap with the symptoms of another form of arthritis called gout, and other autoimmune diseases, such as lupus. Tests can usually reveal which condition you actually have.

    Rheumatoid arthritis can lead to irreversible joint changes over time. Without early and aggressive treatment, inflammation of the joint can lead to damage of the protective cartilage cushions, erosion of bone, and weakening of the tissues that normally support the joints (muscles, tendons, and ligaments) over time. This damage leaves the joints more susceptible to injury, and often results in deformities of the hands and feet that are usually irreversible. The chronic inflammation in the hands may cause the fingers to assume an unnaturally bent or crooked appearance.

    Rheumatoid arthritis can lead to inflammation in other parts of the body, and to other problems, such as rheumatoid nodules Figure 02. These effects most commonly occur in people with high levels of rheumatoid factor Table 02.

    Click to enlarge: Rheumatoid Nodules

    Figure 02. Rheumatoid Nodules

    Table 2.  Possible Effects of Rheumatoid Arthritis

    Rheumatoid nodules are firm, round, painless growths that occur under the skin, often near the elbow joints or other bony structures, like the hand joints. These nodules occur in about 20% of people with rheumatoid arthritis.
    Muscle weakness and loss of muscle mass may occur early in the course of rheumatoid arthritis and most commonly occur around inflamed joints
    Rheumatoid vasculitis is an inflammation of the blood vessels that can affect any organ from the skin to the brain.
    Heart and lung complications can result from inflammation of the tissue surrounding the heart and the lungs and the lung itself,.
    Neurologic symptoms can result from inflammation of the spine and the resulting instability of the upper spine, or from trapping of nerves by inflamed tissues (for example, carpal tunnel syndrome), or due to nerve damage from vessel inflammation.
    Inflammation of the eye occurs in less than 1% of people with rheumatoid arthritis.
    Sj?gren's syndrome can occur in people with rheumatoid arthritis. This autoimmune disease is characterized by dryness of mucous membranes, especially the membranes of the eyes and mouth.
    Felty's syndrome can occur in people with rheumatoid arthritis and is characterized by enlargement of the spleen and a decreased number of immune cells that help to fight off infections.
    Osteoporosis is a condition characterized by thinning of the bones. This condition can occur in people with rheumatoid arthritis as a result of inflammation and decreased physical activity, and is worsened by steroid treatment.

    Genetics and gender partly determine your risk of rheumatoid arthritis. If your mother, father, or sibling has the disease, or if you are a woman, your risk increases. Your total risk for rheumatoid arthritis probably depends on a complex interaction of many different factors. Only a few of these factors have been identified. Genetics play a role in your risk of rheumatoid arthritis. If any of your first-degree relatives (mother, father, and siblings) have rheumatoid factor—positive rheumatoid arthritis, your risk of developing the disease increases fourfold.

    Gender also plays a role in a person's risk for rheumatoid arthritis. Prior to age 60, rheumatoid arthritis affects almost three times as many women as men. After that age, men and women are affected at about the same rate. However, middle age is the most common time for it to develop. Only 30% of patients with RA develop it over the age of 60.

    The symptoms of rheumatoid arthritis may be present for months before the disease is diagnosed. In 90% of people, rheumatoid arthritis has a gradual onset. You may feel very tired, notice a loss of appetite, feel generally weak, and have muscle and joint aches. The actual joint swelling, warmth, redness, and restricted movement may not become evident for months.

    The diagnosis of rheumatoid arthritis begins with a thorough medical history and physical exam. The history addresses the nature, severity, and duration of your symptoms as well as your family history. Your doctor will thoroughly inspect the joints for swelling, redness, warmth, and restricted movement. Your doctor will also examine your spleen to see if it is enlarged, a rare complication of RA. Examination of the skin and testing of tendon reflexes and muscle strength can also reveal signs that suggest rheumatoid arthritis. A general physical exam can help detect or rule out other medical conditions with similar symptoms.

    The diagnosis is based on the patient's symptoms and the findings on the physical examination. Tests help to confirm suspected rheumatoid arthritis, but no single test establishes the diagnosis. When the results of a medical history and physical exam suggest rheumatoid arthritis, a variety of tests can help to confirm a diagnosis. These blood tests include levels of rheumatoid factor, the presence and level of ANA, and an elevation in a marker of inflammation, the ESR, or sedimentation rate. Unfortunately, none of these tests alone provides proof-positive evidence that rheumatoid arthritis is present. For example, the rheumatoid factor test is positive in up to 80% of people with rheumatoid arthritis. However, some people with the disease have a negative test result, and some healthy people and people with other diseases have a positive test result. Your doctor will probably take x-rays of affected joints in addition to blood tests. These x-rays may show the joint erosion typical of RA.

    There is currently no way to prevent rheumatoid arthritis. Because the cause of rheumatoid arthritis is unknown and the risk factors are still being clarified, it is not possible to prevent rheumatoid arthritis. Many people with an inherited risk of rheumatoid arthritis never develop the disease. If you have RA, your doctor will probably treat you with medication early in the disease process to help prevent more severe, chronic joint changes.

  • Prevention and Screening

    There is currently no way to prevent rheumatoid arthritis. Because the cause of rheumatoid arthritis is unknown and the risk factors are still being clarified, it is not possible to prevent rheumatoid arthritis. Many people with an inherited risk of rheumatoid arthritis never develop the disease. If you have RA, your doctor will probably treat you with medication early in the disease process to help prevent more severe, chronic joint changes.

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