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Rheumatoid Arthritis

Rheumatism is a painful condition arising from articular or other elements of musculoskeletal system. Rheumatoid arthritis is a chronic disease of connective tissue, commoner in women than men. In its typical form, it is a symmetrical, destructive and deforming polyarthritis affecting small and large peripheral joints with associated systemic disturbance, a variety of extra articular features and the presence of circulating anti-globulin antibodies (rheumatoid factors). It is the second most common form of joint disease, which usually affects the feet, ankles, fingers and wrists. The condition is diagnosed by means of x-rays, which show a typical pattern of changes around the inflamed joints known as rheumatoid erosions.

The onset is insidious with joint pain, stiffness and symmetrical swelling of a number of peripheral joints. Initially pain may be experienced only on movement of joints, but rest pain and morning stiffness are characteristic features. Small joints of the toes and fingers are the first to be affected. On progression the disease affects wrists, elbows, shoulders, knees, ankles, hips and spine. As the disease advances, muscle atrophy, tendon sheath and joint destruction result in limitation of joint motion, joint instability, subluxation and deformities. The deformities lead to greater loss of joint function. These include the swan neck deformity, the buttonhole deformity and a Z deformity of the thumb. Anorexia, weight loss, lethargy and myalgia occur through out its course.
At first there is swelling of the joint and inflammation of the synovial membrane, followed by the erosion and loss of cartilage and bone. In addition, the blood test reveals the presence of serum rheumatoid factor antibody, which is the characteristic of this condition.

Persons most commonly affected: All age groups and both sexes, but especially women and more common in those aged 30 to 50.

Symptoms and indications:

The symptoms are pain and swelling, restriction of movements, redness and warmth of the skin. The symptoms usually arise slowly and insidiously, but may occasionally be rapid in onset. There is inflammation, tenderness or pain in the affected joints, and stiffness, especially on first getting up in the morning. Deformities of affected joints are likely to develop.

The exact cause is not known. Rheumatoid arthritis is an autoimmune inflammatory arthropathy presenting with morning stiffness in and around joints, soft tissue swelling of three or more joints, symmetric arthritis, rheumatoid nodules, presence of rheumatic factor and roentgenographic erosions and/or periarticular osteopaenia.
The characteristic feature is a small knot or nodule of inflamed fibrous tissue; these tender nodules are often just under the skin. Any organ may on occasion be affected, but most of the symptoms arise from inflammation of the fibrous connective tissue around joints. Any joint may be affected but the knuckle joints and wrists tend to suffer most.

The course of the disease varies widely. In most cases, the inflammation occurs without doing much damage; though further attacks are possible less often a sort of grumpling inflammation persists and the affected joints are stiffened by damage to their linings of smooth cartilage. In severe case joints may become crippled. This is partly due to direct damage to the joint linings, and partly to the action of muscles around the joint. The muscles over any seat of inflammation tighten as a defensive reaction, and when this happens around damaged joint, the joint may in time be deformed or even dislocated.

Treatment:

Rest in bed in active phase of the disease is essential, and adequate rest and good nutrition are important at all times. Many patients will improve with the treatment and the condition varies greatly in the degree of severity. At its worst, it is progressively and severely disabling.

Risk factors:

Most affected people have a particular antibody – HLA-DR4 – but there are likely to be other factors involved, including a family tendency for the disease. Physical and emotional stress play some part in setting off attacks, and there may also be hereditary factors. The immediate damage of joints is probably due to the release of destructive enzymes from inflamed cells. On long standing cases it will change to septic arthritis.

A poor prognosis may be associated with high titres of rheumatoid factor, insidious onset of disease, more that a year of active disease without remission, early development of nodules and erosions and extra-articular manifestations.

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