Hatem H Eleishi, MDProfessor of Rheumatology, Cairo UniversityConsultant Rheumatologist, Dr. Soliman Fakeeh Hospital
Rheumatoid ArthritisWednesday, April 29th, 2009
Lecture 1Rheumatoid Arthritis
From the General Practitioner’s Perspectiveto the Basic Rheumatologist’s Perspective
WHAT MANY DOCTORS KNOW ABOUT RHEUMATOID ARTHRITIS
WHAT MANY DOCTORS MIGHT NOT KNOW ABOUT RHEUMATOID ARTHRITIS
IN THIS LECTURE
RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT
CLINICALLY:POLYARTHRITISIN TIME, CRIPPLING JOINT DEFORMITIES
LABORATORY: POSITIVE RF, HIGH ESR
PLAIN RADIOLOGY: ARTICULAR EROSIONS
MANAGEMENT: NO REAL TREATMENT; ONLY NSAIDs, MAY BE STEROIDSMTX WHICH IS VERY TOXIC
AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY:
IN SHORT
A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT
RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT
PRESENTATION LABS IMAGING MANAGEMENT
ABOUT THE PRESENTATION OFRHEUMATOID ARTHRITIS
IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO;
TRUE: THE MOST COMMON PRESENTATION ISA SYMMETRICAL POLYARTHRITIS
WE HAVE
THE RELUCTANT RA
THE STUTTERING RA
THE DISGUISED RA
THE ACHES ALL OVER RA
THE PUFFY RA
A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS.
DURATION OF EACH ATTACK: 3-7 DAYS
ATTACK FREE PERIOD: 2-3 MONHTS
THE RELUCTANT RA
OR PALINDROMIC RHEUMATISM
PRESENTATION 1 OF 5
2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRISTPLAIN FILM OF HER HANDS: NORMALMRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA
EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST
S T U T T E R I N G RA
LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES
ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS
PRESENTATION 2 OF 5
RA RA
FEMALE; 48Y-OLDOA KNEES / HANDS
LATELY PAINNOCTURNAL PAINSREC EFFUSIONS
PLAINS: OAESR 50RF +VESYNOVIONALYSIS: INFLAMMATORY SF
RA ON TOP OF OA OR DISGUISED RA
PRESENTATION 3 OF 5
Mona, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of 10-60 minutes and nocturnal pain sometimes.
She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative.
PRESENTATION 4 OF 5
Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs.
Investigations: ESR 21CBC, liver, kidney, electrolytes: normalRF; ANA: negativeHepatitis serology: negativeA plain film of the hands and feet were normal
DIFFUSE ACHES ALL OVER RA
OR FIBROMYALGIC RA
A Tc99 bone scan was done
Early rheumatoid arthritis can sometimes be
a vague diagnosis
Bone scan helps to settle the diagnosis
in such situations
Abu-Ismail, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hoursExamination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wristsLABS: ESR 70; Hb 11gm%; RF: Negative
RS3PE REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS
WITH PITTING EDEMA OR PUFFY RA
PRESENTATION 5 OF 5
THE RELUCTANT RA
THE STUTTERING RA
THE SNEEKY RA
THE ACHES ALL OVER RA
THE PUFFY RA
RHEUMATOID ARTHRITIS
AS MANY DOCTORS MIGHT NOT KNOW IT
PRESENTATION LABS IMAGING MANAGEMENT
ABOUT THE LABORATORY INVESTIGATIONS
IN RHEMATOID ARTHRITIS
THERE ARE CAUSES FOR A POSITIVE RF OTHER THAN RA
SO YOU CANNOT RELY SOLELY ON A POSITIVE RF TO DIAGNOSE RA
POSITIVE RHEUMATOID FACTOR“THE RHEUMATOID CETRTIFICATE”
RHEUMATOID FACTOR IS POSITIVE IN ONLY 70% OF PATIENTS AND NEGATIVE IN 30%
SO A NEGATIVE RF DOESN’T RELIABLY EXCLUDE RA
NEGATIVE RHEUMATOID FACTOR
ESR IS NOT INVARIABLY ELEVATEDIN RA
ESR
ABOUT THE IMAGING OFRHEUMATOID ARTHRITIS
NOT EVERY RHEUMATOID DISEASE IS NECESSARILY EROSIVE
BEFORE LOOKING FOR EROSIONS, LOOK FIRST FOR: JAOJSN
IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY
OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS
What is the most important thing that is needed to make the diagnosis of RA?
A good lab
An imaging center
A chair
A screening questionnaire for the population
Knowing the family history of your patient
Two doctors rather than one
HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO THE CORRECT DIAGNOSIS
THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT:
THE POLICE OFFICER’S HISTORY
THE JOURNALIST’S HISTORY
THE GOOD DOCTOR’S HISTORY
GOOD DOCTORS DO NOT
DIAGNOSE DISEASES
THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES
لكل ، البشر مثل األمراضو المميزة مالمحه مرضالتي الخاصة طبائعهو تزداد ثم الطبيب يدرسهابها معرفته تصقلو البحث و بالممارسة
المستمر .اإلطالع
أثناء في المميزة المالمح هذه على الطبيب يتعرفالمريض مع الحوار
هي المرض لتشخيص خطوة أهم فإن هذا :وعلى
على إجاباته إلى و المريض إلى الجيد اإلستماعالطبيب أسئلة
إجاباته إلى و المريض إلى الجيد باإلستماع يحدث ماذاالطبيب؟ أسئلة على
في المريض يقع ........حفرة
يسيبه يقع
لوحده، ما يزقوش
يفعل ماذاالطبيب هذه في الحالة؟
ABOUT THE MANAGEMENT OFRHEUMATOID ARTHRITIS
MANAGEMENT OF RA COMPRISES:
PATIENT EDUCATION AND INSTRUCTIONS
MEDICAL TREATMENT
REHABILITATION
SURGICAL TREATMENT SOMETIMES
DON’T UNDERESTIMATE THE POWER OF TALKING TO YOUR PATIENT
PATIENT EDUCATION
MEDICAL TREATMENT
REHABILITATION
NSAIDs AND PHYSIOTHERAPY
Hydroxychloroquine, sulfasalazine, gold
Methotrexate, lefulonamide
Biological Agents
Aim of medical treatment: Induction and maintenance of remission
Severe systemic
illness
Bridge therapy
Intra-articular steroids
Corticosteroids are not part of the medical treatment of RA except in very selected situations as:
Conclusions
THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST:
A CRIPPLING JOINT DISEASE WITH A POSITIVE RF
AND NO TREATMENT
A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION,
BUT
THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL
PRESENTATION
THE MOST IMPORTANT STEP TOWARDS A DIAGNOSIS OF RA IS
A GOOD HISTORY TAKEN BY A GOOD DOCTOR
PRESENTATION
A POSITIVE RF DOESN’T NECESSARILY MEAN RA
AND
A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA
INVESTIGATIONS
PLAIN FILMS IN EARLY RA
MAY BE NORMAL
INVESTIGATIONS
DOCTORS ARE MORE THAN JUST
TABLETS
MANAGEMENT
A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS
PATIENT EDUCATION
MANAGEMENT
CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF
RA EXCEPT IN
VERY SPECIAL SITUATIONS
MANAGEMENT
VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS
MANAGEMENT
Thank you