5/31/2016
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`Rheumatoid Arthritis Symptoms for RA Patients
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`You are here: Home / Arthritis Information / Rheumatoid Arthritis / Rheumatoid Arthritis Signs and Symptoms
`
`Rheumatoid Arthritis Signs and
`Symptoms
`
`by Victoria Ruf(cid:214)ng, R.N., C.C.R.P. and Clifton O. Bingham III, M.D.
`
`Epidemiology
`Clinical History
`Physical Examination
`
`RHEUMATOID ARTHRITIS
`NEWS
`
`http://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-symptoms/
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`Rheumatoid Arthritis Symptoms for RA Patients
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`Extra-Articular Disease
`Laboratory Tests
`Radiographic Findings
`Clinical Course
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`Epidemiology
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`Rheumatoid arthritis has a worldwide distribution with an estimated
`prevalence of 1 to 2%. Prevalence increases with age, approaching 5% in
`women over age 55. The average annual incidence in the United States is
`about 70 per 100,000 annually. Both incidence and prevalence of
`rheumatoid arthritis are two to three times greater in women than in men.
`Although rheumatoid arthritis may present at any age, patients most
`commonly are (cid:214)rst affected in the third to sixth decades.
`
`Clinical History
`
`The typical case of rheumatoid arthritis begins insidiously, with the slow
`development of signs and symptoms over weeks to months. Often the
`patient (cid:214)rst notices stiffness in one or more joints, usually accompanied by
`pain on movement and by tenderness in the joint. The number of joints
`involved is highly variable, but almost always the process is eventually
`polyarticular, involving (cid:214)ve or more joints.(cid:98) Occasionally, patients
`experience an explosive polyarticular onset occurring over 24 to 48 hours.
`Another pattern is a palindromic presentation, in which patients describe
`
`Will Exercise Cause Damage To
`My Joints Or Cause A Flare?
`
`Dental Health And Rheumatoid
`Arthritis: A Research Update
`
`Arthritis Center Researchers Find
`That Yoga Improves Arthritis
`Symptoms And Mood
`
`Normal Rheumatoid Factor Levels
`
`If my lab results are <15.0 for my ra fact is this
`normal. And if not how much is it over the
`range. Thank you so much.
`
`What Is Rheumatoid Factor?
`
`85 yrs old. Recent blood work with a
`Rheumatoid Factor reading of 695. What is
`normal reading? Past few months burning &
`tingling in ankles & legs.
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`Methotrexate Side Effects
`
`Have recently been prescribed methotrexate
`tablets for RA. I’m really worried to take them
`as they work by dampening the immune
`system. Would that not leave my immune
`system weak to (cid:214)ght infections ?
`
`More Rheumatoid Arthritis Expert Questions
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`5/31/2016
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`Rheumatoid Arthritis Symptoms for RA Patients
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`swelling in one or two joints that may last a few days to weeks then
`completely go away, later to return in the same or other joints, with a
`pattern increasing over time.
`
`The joints involved most frequently are the proximal interphalangeal (PIP)
`and metacarpophalangeal (MCP) joints of the hands, the wrists, and small
`joints of the feet including the metatarsophalangeal (MTP) joints.(cid:98) The
`shoulders, elbows, knees, and ankles are also affected in many patients.
`The distal interphalangeal (DIP) joints are generally spared. With the
`exception of the cervical spine, the spine is unaffected.
`
`Nonspeci(cid:214)c systemic symptoms primarily fatigue, malaise, and depression,
`may commonly precede other symptoms of the disease by weeks to
`months and be indicators of ongoing disease activity. Fatigue can be an
`especially troubling feature of the disease for many patients.(cid:98) The pattern
`of symptoms may wax and wane over the course of a day and even from
`one day to the next.(cid:98) Sometimes “(cid:215)ares” of RA are experienced as an
`increase in these systemic symptoms more than discrete joint swelling or
`tenderness.(cid:98)(cid:98) Fever occasionally occurs and is almost always low grade (37°
`to 38°C; 99° to 100°F). A higher fever suggests another illness, and
`infectious causes must be considered, especially in patients who are taking
`biological therapies and immunosuppressive medications.
`
`Morning stiffness, persisting more than one hour but often lasting several
`hours, may be a feature of any in(cid:215)ammatory arthritis but is especially
`characteristic of rheumatoid arthritis. Its duration is a useful gauge of the
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`in(cid:215)ammatory activity of the disease. Similar stiffness can occur after long
`periods of sitting or inactivity (gel phenomenon). In contrast, patients with
`degenerative arthritis complain of stiffness lasting but a few minutes.
`
`Physical Examination
`
`Symmetrical joint swelling is characteristic of rheumatoid arthritis that has
`been persistent for a period of time.(cid:98) However when only a few joints are
`affected at the beginning of disease, symmetry may not be seen and should
`not preclude the diagnosis of RA.(cid:98) Careful palpation of the joints can help to
`distinguish the swelling of joint in(cid:215)ammation from the bony enlargement
`seen in osteoarthritis, with the swelling often described as being doughy or
`spongy in RA in contrast to (cid:214)rm knobby enlargement in osteoarthritis.
`Swelling of the PIP and MCP joints of the hands is a common early (cid:214)nding
`(Pictured below).(cid:98)Wrists, elbows, knees, ankles and MTP are other joints
`commonly affected where swelling is easily detected. Pain on passive
`motion is a sensitive test for joint in(cid:215)ammation as is squeezing across the
`MCPs and MTPs. Occasionally in(cid:215)amed joints will feel warm to the touch.
`In(cid:215)ammation, structural deformity, or both may limit the range of motion
`of the joint. Over time, some patients with RA develop deformities in the
`hands or feet. RA spares the distal joints of the (cid:214)ngers (DIPs) and the spine
`with the exception of the cervical spine (especially the atlanto-axial joint at
`C1-C2), which may become involved especially with longer standing
`disease.
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`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`of Rheumatology.
`
`Permanent deformity is an unwanted result of the in(cid:215)ammatory process.
`Persistent tenosynovitis and synovitis leads to the formation of synovial
`cysts and to displaced or ruptured tendons. Extensor tendon rupture at the
`dorsum of the hand is a common and disabling problem.
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`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`of Rheumatology.
`
`Advanced(cid:98)changes in RA (shown below) include ulnar deviation of the
`(cid:214)ngers at the MCP joints, hyperextension or hyper(cid:215)exion of the MCP and
`PIP joints, (cid:215)exion contractures of the elbows, and subluxation of the carpal
`bones and toes (cocked -up).
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`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`of Rheumatology.
`
`Extra-Articular Disease
`
`Although the joints are almost always the principal focus of RA, other
`organ systems may also be involved. Extra-articular manifestations of RA
`occur most often in seropositive patients with more severe joint disease.
`Extra-articular manifestations can(cid:98)develop even(cid:98)in disease when there is
`little active joint involvement.
`
`Rheumatoid Nodules. The subcutaneous nodule is the most characteristic
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`extra-articular lesion of the disease. (cid:98) Nodules occur in 20 to 30% of cases,
`almost exclusively in seropositive patients.(cid:98) They are located most
`commonly on the extensor surfaces of the arms and elbows (shown
`below)but are(cid:98)also prone to develop at pressure points on the feet and
`knees. Rarely, nodules may arise in visceral organs, such as the lungs, the
`heart, or the sclera of the eye. (learn more about rheumatoid nodules in
`case report #6)
`
`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`of Rheumatology.
`
`Cardiopulmonary Disease.(cid:98)(cid:98) There are several pulmonary manifestations
`of rheumatoid arthritis, including pleurisy with or(cid:98)without effusion,
`intrapulmonary nodules, and diffuse interstitial (cid:214)brosis. On(cid:98)pulmonary
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`function testing, there commonly is a restrictive ventilatory defect
`with(cid:98)reduced lung volumes and a decreased diffusing capacity for carbon
`monoxide.(cid:98)(cid:98)Although mostly asymptomatic, of greatest concern is
`distinguishing these (cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98)(cid:98) manifestations from infection and tumor. (learn
`more about pulmonary complications in rheumatoid arthritis in case report
`#6)
`
`Atherosclerosis is the most common cardiovascular manifestation in
`rheumatoid arthritis.(cid:98)It is also the leading cause of death in the RA patient.
`Because chronic in(cid:215)ammation may be the cause of atherosclerosis, it is
`possible that early aggressive treatment of RA may reduce the incidence or
`severity of heart disease. Pericarditis also seen with RA.
`
`Eye Disease.(cid:98) Keratoconjunctivitis of Sjogren’s syndrome is the most
`common ocular manifestation of (cid:98) rheumatoid arthritis. Sicca (dry eyes) is a
`common complaint. Episcleritis occurs(cid:98)occasionally and is manifested by
`mild pain and intense redness of the affected eye.(cid:98)Scleritis and corneal
`ulcerations are rare but more serious problems.
`
`Sjogren’s Syndrome.(cid:98)Approximately 10 to 15% of patients with
`rheumatoid arthritis develop Sjogren’s syndrome, a chronic in(cid:215)ammatory
`disorder characterized by lymphocytic in(cid:214)ltration of lacrimal and salivary
`glands. Sjogren’s syndrome is an autoimmune condition that affects
`exocrine gland function, leading to a reduction in tear production
`(keratoconjunctivitis sicca), oral dryness (xerostomia) with decreased
`saliva of poor quality, and reduced vaginal secretions.(cid:98)(cid:98)It is important for
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`patients to be seen regularly by the ophthalmologist and dentist.(cid:98)
`Additional medications are sometimes required to treat this condition.(cid:98)(cid:98)A
`polyclonal lymphoproliferative reaction characterized by
`lymphadenopathy is also seen, and patients have an increased risk of
`developing lymphoma. Additional information on Sjogren’s syndrome can
`be found at our Sjogren’s Center website.
`
`Rheumatoid Vasculitis. The most common clinical manifestations of
`vasculitis are small digital infarcts along the nailbeds. (see picture below)
`The abrupt onset of an ischemic mononeuropathy (mononeuritis multiplex)
`or progressive scleritis is typical of rheumatoid vasculitis. The syndrome
`ordinarily emerges after years of seropositive, persistently active
`rheumatoid arthritis; however, vasculitis may occur when joints are
`inactive. Addional information on vasculitis can be found on our Vasculitis
`Center website.
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`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`of Rheumatology.
`
`Neurologic Disease.
`
`The most common neurologic manifestation of rheumatoid arthritis is a
`mild, primarily sensory peripheral neuropathy, usually more marked in the
`lower extremities. Entrapment neuropathies (e.g., carpal tunnel syndrome
`and tarsal tunnel syndrome) sometimes occur in patients with rheumatoid
`arthritis because of compression of a peripheral nerve by in(cid:215)amed
`edematous tissue. Cervical myelopathy secondary to atlantoaxial
`subluxation is an uncommon but particularly worrisome complication
`potentially causing permanent, even fatal neurologic damage.
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`Felty’s Syndrome
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`Rheumatoid Arthritis Symptoms for RA Patients
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`Felty’s syndrome is less commonly encountered than in the past.(cid:98) This is
`characterized by splenomegaly, and leukopenia – predominantly
`granulocytopenia. Recurrent bacterial infections and chronic refractory leg
`ulcers are the major complications.
`
`Clinical Course
`
`The course of rheumatoid arthritis cannot be predicted in a given patient.
`Several patterns of activity have been described:
`
`a spontaneous remission particularly in the seronegative patient
`within the (cid:214)rst 6 months of symptoms (less than 10%)
`recurrent explosive attacks followed by periods of quiescence most
`commonly in the early phases
`the usual pattern of persistent and progressive disease activity that
`waxes and wanes in intensity.
`
`Disability is higher among patients with rheumatoid arthritis with 60%
`being unable to work 10 years after the onset of their disease. Recent
`studies have demonstrated an increased mortality in rheumatoid patients.
`Median life expectancy was shortened an average of 7 years for men and 3
`years for women compared to control populations. In more than 5000
`patients with rheumatoid arthritis from four centers, the mortality rate
`was two times greater than in the control population. Patients at higher
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`risk for shortened survival are those with systemic extra-articular
`involvement, low functional capacity, low socioeconomic status, low
`education, and prednisone use. With the advent of therapies to better
`control in(cid:215)ammation and treatment strategies geared to low disease
`activity and remission, it is hoped that the statistics concerning disability
`and mortality will improve.
`
`Laboratory Tests
`
`No laboratory test will de(cid:214)nitively con(cid:214)rm a diagnosis of rheumatoid
`arthritis. However, the information from the following tests contributes to
`diagnosis and management.
`
`Complete blood count (CBC)
`Comprehensive metabolic panel (CMP)
`Rheumatoid Factor (RF)
`Antibodies to citrullinated peptides including anti-CCP
`Erythrocyte Sedimentation Rate (ESR)
`C-reactive protein (CRP)
`
`The blood count shows a mild anemia in approximately 25 to 35% of
`patients with RA. The white cell count is usually normal in patients with
`rheumatoid arthritis, but can be mildly elevated secondary to
`in(cid:215)ammation, and can also be very low in a subgroup of patients with
`Felty’s syndrome. Similarly, the platelet count is usually normal but
`thrombocytosis occurs in response to in(cid:215)ammation.
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`Chemistry tests are usually normal in rheumatoid arthritis with the
`exception of a slight decrease in albumin and increase in total protein
`re(cid:215)ecting the chronic in(cid:215)ammatory process. Renal and liver function are
`important to check before beginning treatment and are followed over time
`with many medications.
`
`A positive rheumatoid factor is present in 70-80% of patients with RA. A
`positive Anti-CCP is a more speci(cid:214)c marker for RA and is found in similar
`proportions of patients over the course of disease.(cid:98) High levels of Anti-CCP
`also appear to be linked to a greater severity of the disease.
`
`Measures of in(cid:215)ammation are often, but not always increased in RA. The
`erythrocyte sedimentation rate (ESR) is usually elevated in patients with
`RA and in some patients is a helpful adjunct in following the activity of the
`disease. The C-reactive protein (CRP) is another measure of in(cid:215)ammation
`that is frequently elevated, and improves with control of disease activity.
`
`Testing for hepatitis B and C and testing for tuberculosis are commonly
`done as part of an initial evaluation. Baseline X-Rays of the hands, feet, and
`other affected joints are common at initial evaluation, and sometimes a
`baseline chest X-Ray is obtained.
`
`Radiographic Findings
`
`Erosions of bone and destruction of cartilage, occur rapidly and may be
`seen within the (cid:214)rst 2 years of the disease, but continue to develop over
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`time (See picture below). These anatomic changes result in limitations in
`range of motion, (cid:215)exion contractures, and subluxation (incomplete
`dislocation) of articulating bones. Typical deformities include ulnar
`deviation of the (cid:214)ngers at the MCP joints, hyperextension or hyper(cid:215)exion
`of the MCP and PIP joints (swan neck and boutonniere deformities), (cid:215)exion
`contractures of the elbows, and subluxation of the carpal bones and toes
`(hammer toes and cock up deformities). Radiological (cid:214)ndings early in the
`disease may show nothing other than soft tissue swelling. Thereafter,
`periarticular osteopenia may develop. With progression of their disease,
`narrowing of the joint space is caused by loss of cartilage, and juxta-
`articular erosions appear, generally at the point of attachment of the
`synovium. In end-stage disease, large cystic erosions of bone may be seen.
`
`Reprinted from the Clinical Slide Collection on the Rheumatic Diseases,
`copyright 1991, 1995, 1997. Used by permission of the American College
`
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`of Rheumatology.
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`Rheumatoid Arthritis Symptoms for RA Patients
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`More recently the introduction of ultrasound and MRI imaging has
`imporved the sensitivity of detecting joint damage earlier in disease.(cid:98)
`Ultrasound may detect synovitis, effusions, and erosions, in addition to
`power Doppler providing estimates of ongoing in(cid:215)ammation.(cid:98) MRI may
`show in(cid:215)ammatory synovitis that enhances with Gadolinium and shows
`early erosions.(cid:98) The role for these modalities in following patients over time
`in clinical practice is still not well established, but these methods may
`improve the ability to detect early disease and con(cid:214)rm a diagnosis.
`
`Next: Pathophysiology of Rheumatoid Arthritis
`
`9
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`Updated: January 13, 2016
`
`About Clifton Bingham, III, MD
`
`Associate Professor of Medicine
`
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`Rheumatoid Arthritis Symptoms for RA Patients
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`Director - Johns Hopkins Arthritis Center
`
`About Victoria Ruf(cid:214)ng, RN
`
`Ms. Ruf(cid:214)ng has been a member of the Arthritis Center since
`2000, currently serving as the Nurse Manager. She is a
`critical member of our patient care team.
`
`Signs and Symptoms
`
`Pathophysiology
`
`Treatment
`
`Lung Involvement in
`Patients with
`Rheumatoid Arthritis
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