XII Международная студенческая научная конференция Студенческий научный форум - 2020

Table of Contents

Introduction

Classification

General features:

Etiology and pathogenesis:

Clinical features of rheumatoid arthritis:

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disorder which affects the joints and is

associated with swelling, stiffness and pain. Advanced disease stages can lead to substantial

loss of functioning and mobility. RA is an autoimmune disease, whereby the body’s immune

system attacks its own tissues. The triggers for the onset of RA are only speculated, but it is

expected that a genetic liability to the disorder, several viruses and bacteria (e.g. Epstein-

Barr-Virus and Mycobacterium tuberculosis; Miehle, et.al, 2000), disruption of the

immunological tolerance as well as the psychological condition by further weakening the

immune system of people concerned could play a major role (Breitenberger, 2008). As the

causes for RA are still unknown, cures have not been discovered yet as well. All treatments

and therapies which are applied so far are intended largely to reduce symptoms and delay

the progress of the disease (Newman & Fitzpatrick, 1995). The onset of RA arises usually

between the age of 30 and 50, but may also occur at any other age. Women are three times

more affected by it than men and people who are less educated and with fewer

socioeconomic resources experience more problems emerging of RA. About 1% of the whole world population is attacked by rheumatoid arthritis (Majithia & Geraci, 2007) whereof about 790,000 people in the Netherlands are affected (Reumafonds, 2009)

The Progression of Rheumatoid Arthritis

Rheumatoid arthritis begins with the inflammation of the synovial membrane of the joints,

especially in the small ones of the fingers and feet and is mostly bilateral. The inflammatory

cells, if in inappropriate large amount, destroy body tissue. The synovial fluid accumulates

and the joints swell in time and thicken into a pannus (abnormal tissue). Over time the

pannus erodes the joint’s cartilage and, possibly, scar tissue will be formed, connecting bone

ends. Later this scar tissue can ossify wherewith the joints get immobilized and deformed.

The surrounding structures of the inflammatory joints, as tendon sheaths, bursas and origins

of muscles are often involved supporting joint deformations as well. These strains are

generally irreversible (Marieb, et.al, 2006). In seldom cases the vertebral column,

vasculatures and several organs as skin, heart and lungs are also inflamed by RA. The disease gets diagnosed by several methods: ultrasound and MRI (magnetic resonance imagery) which detects inflammation marks in the joints and the surrounding structures; radiograph and MRI which detects meanderings in cartilage and bones. The progress of RA differs clearly from person to person.

DEFINITION

Rheumatoid arthritis is a long-term, progressive, and disabling autoimmune disease. It causes inflammation, swelling, and pain in and around the joints and other body organs RA is an autoimmune disease. It is also a systemic disease, which means it affects the whole body.

The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies and immune cells in their blood that target their own body tissues, where they can be associated with inflammation. While joint tissue inflammation and inflammatory arthritis are classic RA features, the disease can also cause extra-articular inflammation and injury in other organs.

Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

It occurs when a person's immune system mistakes the body's healthy tissues for foreign invaders.

As the immune system responds, inflammation occurs in the target tissue or organ.

In the case of RA, this can be the joints, lungs, eyes, and heart.

RA is also known to be associated with higher risks for lymphoma, anemia, osteoporosis, and depression.

CLASSIFICATION

Inflammatory arthritis is generally classified into seropositive and seronegative groups. These are based on the presence of rheumatoid factor, an immunoglobulin which reacts with gamma globulin, in the blood of the majority of patients with seropositive disease and in a small minority of patients with seronegative disease. The prototype seropositive form of arthritis is rheumatoid arthritis. Other members include the group of conditions labelled collagen vascular diseases, such as systemic lupus erythematosus, scleroderma, vasculitis, Sjogren’s syndrome. Only rheumatoid arthritis will be considered in this paper.

Among the seronegative inflammatory joint diseases is a group labelled spondyloarthritis. This condition is characterized by inflammatory disease of the joints of the back, both the sacroiliac joints and the apophyseal joints of the spine. Members of this group include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and arthritis of inflammatory bowel disease. While the prototype for this group is ankylosing spondylitis, psoriatic arthritis will also be discussed.

In addition to the presence of rheumatoid factor, there are extra-articular features which distinguish the seropositive from the seronegative forms of inflammatory arthritis.

GENERAL FEATURES:

Rheumatoid arthritis is an inflammatory arthritis affecting both small and large joints in a symmetric distribution. The disease affects women more than men and usually begins in the 4th decade although may occur at any age. It presents with pain and swelling in the affected joints, associated with prolonged morning stiffness and quickly leads to limitation of daily activities. In addition to the peripheral arthritis, rheumatoid arthritis may affect internal organs such as the heart, lungs, skin, and peripheral nerves. When systemic manifestations are present the condition is often referred to as rheumatoid disease.

Etiology and Pathogenesis:

The cause of rheumatoid arthritis is unknown. However, factors considered important in its development include genetic, immunological and environmental factors.

Genetic factors: It is well recognized now that genes at the major histocompatibility complex (MHC) are associated with rheumatoid arthritis. In humans, the MHC is located on the short arm of chromosome 6 and is termed HLA (Hunan Leukocyte Antigens). HLA-DRB*0401 has been identified as a risk factor for the development of rheumatoid arthritis. It has further been demonstrated that there is a conserved amino acid sequence which maps to the third hypervariable region of HLA-DR beta chains containing amino acids 70-74, known as the “shared epitope”. The shared epitope occurs in a number of HLA alleles which have been associated with rheumatoid arthritis is various ethnic groups. Whether this shared epitope plays a direct role in the immune response leading to rheumatoid arthritis, or whether it is related to the production of autoantibodies directed against cyclic citrulinated peptide (CCP) is still being debated. Polyomorphisms in several other genes may also contribute to the development of rheumatoid arthritis.

Other Risk Factors: Non genetic risk factors include female sex, as women are 2-3 times more likely to develop rheumatoid arthritis than males, Hormonal factors such as estrogen and progesterone may potentially explain the gender effect. While estrogen is associated with an effect on the immune response its role in the development of rheumatoid arthritis remains controversial.

Several environmental factors have been implicated in the etiology of rheumatoid arthritis.  Exposure to tobacco is the best characterized. It turns out that smoking enhances the risk of developing anti-CCP antibodies which occur commonly among patients with rheumatoid arthritis, and have been detected long before the diagnosis of the disease. It is hypothesized that inhaled smoke generates anti-CCP antibodies which in turn lead to inflammation and activation of innate immunity eventually leading to rheumatoid arthritis. Infectious agents have also been implicated in the development of rheumatoid arthritis, although no specific agent has yet been identified. Stress, either physical or psychological has been proposed as a mechanism for the development of autoimmune diseases such as rheumatoid arthritis, as stress leads to immune dysregulation in a similar way that occurs in rheumatoid arthritis. While patients with rheumatoid arthritis may provide a history of stress prior the onset of the disease, there are no studies that identify a particular for of trauma as associated with the disease.

Immune pathogenesis: Whatever the cause of RA, the disease is associated with a number of immunologic alterations. It is thought that through genetic and environmental factors there is activation of innate immunity and antigen loading onto macrophages. This leads to inflammatory cell recruitment, including polymoprhonucelar cells, T cells B cells and osteoclasts. Through activation of T cells there is production of cytokines, activation of B cells and autoantibody production, immune complex formation and deposition within the synovium. Once it starts, the process seems self-perpertuating leading to synovial cell proliferation and cartilage and bone destruction. 

Clinical features of Rheumatoid Arthritis:

 Rheumatoid arthritis affects primarily small and medium sized joints in a symmetric distribution. The joints are painful and swollen and the morning stiffness is usually prolonged. It usually spares the distal interphalangeal joints of the hands and feet, and usually does not affect the joints of the spine. The most common extra articular feature of rheumatoid arthritis is the rheumatoid nodule, which occurs most commonly on the extensor surfaces of the forearm near the elbow, but can occur at any site of pressure. The nodule is usually soft, non painful. The rheumatoid nodules can develop in the lungs and other internal sites, including the spinal canal in which case they may lead to spinal symptoms.

In addition to the joint inflammation, internal organs may be affected by the rheumatoid process. The eye is commonly affected with dry eyes, conjunctivitis, and inflammation in different parts of the eye including episcleritis, and scleritis. In the lungs, rheumatoid nodules can occur which can be confused with cancer. Interstitial lung disease may develop in patients with rheumatoid arthritis, particularly smokers, and may lead to severe shortness of breath. Inflammation of the lining of the lung, pleurisy may also occur leading to chest pain and shortness of breath. In the heart  rheumatoid nodules may occur and may interfere with the conduction system leading to irregular heart beat. Alternatively, inflammation of the heart muscle, myocarditis may occur, or inflammation in the lining of the heart, pericarditis may develop, both leading to chest pain and possibly shortness of breath. The peripheral nervous system is affected by compression neuropathies such as carpal tunnel syndrome. Occasionally patients with rheumatoid arthritis present with an inflammatory neuropathy which may lead to paraesthesias or numbness and sometimes dysfunction. In addition cervical myelopathy may occur secondary to vertebral subluxation in the neck. This may present with headaches, numbness, loss of balance or in severe cases frank paralysis. In addition to the subcutaneous nodules the skin may demonstrate vasculitis which may present with redness around the nail bed as well as hemorrhages in the fingers, or with large ulcers particularly on the medial aspect of the lower extremities as is seen in patients with Felty’s syndrome, in which the arthritis is coupled with a large spleen, low platelet countand skin ulcers.

Early Signs and Symptoms of Rheumatoid Arthritis (RA)

While early signs of rheumatoid arthritis can actually be mimicked by other diseases, the symptoms are very characteristic of rheumatoid disease. Rheumatoid arthritis signs and symptoms include the following:

Fatigue

Joint pain

Joint tenderness

Joint swelling

Joint redness

Joint warmth

Joint stiffness

Loss of joint range of motion

Limping

 

Natural history: 

If left untreated rheumatoid arthritis leads to deformities, joint destruction and premature death.  Patients with rheumatoid arthritis are at an increased risk of death, as well as cardiovascular disease, including myocardial infarction and strokes.

Diagnosis:

The diagnosis of RA is made on the basis of the history of inflammatory joint disease, physical examination demonstrating evidence of arthritis usually in a symmetric distribution, laboratory confirmation with a positive rheumatoid factor test, and x-rays confirming erosive disease in the appropriate distribution. The American College of Rheumatology has developed classification criteria which include the presence of morning stiffness, arthritis in 3 or more joint areas, arthritis of the hand joints, symmetric arthritis, rheumatoid nodules, positive rheumatoid factor and radiographic changes. The radiographic changes include erosions which are most common in the wrists, metacaropophalangeal joints of the hands, and the metatarsophalangeal joints of the feet. The presence of 4 or more of these items classifies a patient as having rheumatoid arthritis..

Role of trauma:

 As noted above, stress may aggravate the immune response leading to changes similar to those occurring in rheumatoid arthritis thus stress may lead to exacerbations of the disease. However, a specific role for trauma in the development of rheumatoid arthritis has not bee proven. On the other hand, since compression neuropathies may occur, repetitive movement may aggravate some aspects of rheumatoid arthritis. Unfortunately there is no evidence in the literature to help understand the role of trauma in either the development or perpetuation of rheumatoid arthritis.

LITERATURE

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Affleck, G., Tennen, H., Urrows, S. & Higgins, P. (1992). Neuroticism and the pain-mood relation in rheumatoid arthritis: Insights from a prospective daily study. Journal of Consulting and Clinical Psychology, 60 (1), 119-126.

Affleck, G., Tennen, H., Keefe, F.J., Lefebvre, J.C., Kashikar-Zuck, S., Wright, K., Starr, K. & Caldwell, D.S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: independent effects of disease and gender on daily pain, mood and coping. Pain, 83, 601-609.

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Links

http://www.wsiat.on.ca/english/mlo/arthritis.htm

https://emedicine.medscape.com/article/331715-overview

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