eMedicine Specialties > Emergency Medicine > Rheumatology

Arthritis, Rheumatoid

Author: Randall W King, MD, FACEP, Assistant Clinical Professor of Emergency Medicine, The University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center
Coauthor(s): Richard Worthington, MD, Assistant Clinical Professor, Program Instructor, Department of Emergency Medicine, St Vincent Mercy Medical Center
Contributor Information and Disclosures

Updated: Jun 15, 2010

Introduction

Background

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of undetermined etiology involving primarily the synovial membranes and articular structures of multiple joints. The disease is often progressive and results in pain, stiffness, and swelling of joints. In late stages, deformity and ankylosis develop. Rheumatoid arthritis can also cause significant extra-articular manifestations most probably related to systemic inflammation.1

Pathophysiology

The cause of rheumatoid arthritis (RA) is unknown. The diagnosis is based routinely on the persistence of arthritic symptoms over time. The application of classification systems based on qualifying symptom criteria or on decision-tree methodology also aids in establishing a diagnosis.

Factors associated with rheumatoid arthritis include the possibility of infectious triggers, genetic predisposition, and autoimmune response. CD4+ T cells stimulate the immune cascade leading to cytokine production such as tumor necrosis factor alpha (TNF-a) and interleukin-1.

The primary targets of inflammation are synovial membranes and articular structures. Other organs are affected as well. Inflammation, proliferation, and degeneration typify synovial membrane involvement. Joint deformities and disability result from the erosion and destruction of synovial membranes and articular surfaces.

The disease course may be short and limited or progressive and severe.

Frequency

United States

Prevalence is approximately 1% in the United States. The occurrence rate ranges from 0.5% to greater than 5% depending on ethnic variation.

International

Prevalence of rheumatoid arthritis is similar to that in the United States and ranges from 0.5-5%.

Mortality/Morbidity

Mortality from rheumatoid arthritis (RA) is related primarily to the patient's overall deterioration in health, well-being, and functionality. Patients with rheumatoid arthritis become susceptible to infection and secondary organ dysfunction (eg, lung disease, kidney disease, GI hemorrhage). Rheumatoid arthritis also leads to significant increased development of atherosclerotic cardiovascular disease.2

Race

Rates for arthritis vary from approximately 5-6% in Asian/Pacific Islanders to 12% in African Americans and 16% in whites.

Sex

Female-to-male ratio is approximately 3:1.

Age

Age of onset is usually between 25 and 50 years. Rheumatoid arthritis can occur at any age but tends to peak in the fourth and fifth decades of life. The pediatric form of rheumatoid arthritis is juvenile rheumatoid arthritis (JRA), which is characterized by onset in children younger than 16 years and includes 3 categories of disease: polyarticular (ie, multiple joints affected), pauciarticular (ie, fewer than 4 joints affected), and systemic (ie, high fever, rash, organ involvement).

Clinical

History

  • Rheumatoid arthritis (RA) is usually a disease of insidious onset, although it can be abrupt. The diagnosis typically is made when 4 of 7 qualifying criteria established by the American Rheumatism Association are met. These qualifying criteria are as follows:
    • Morning joint stiffness lasting longer than 1 hour before maximal improvement
    • Arthritis involving 3 or more joints
    • Arthritis of the hand, shown in the photo below, particularly involvement of the proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, or wrist joints

    • Rheumatoid changes in the hand. Photograph by Dav...

      Rheumatoid changes in the hand. Photograph by David Effron, MD, FACEP.

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      Rheumatoid changes in the hand. Photograph by Dav...

      Rheumatoid changes in the hand. Photograph by David Effron, MD, FACEP.

    • Bilateral involvement of joint areas (ie, both wrists, symmetric PIP and MCP joints)
    • Positive serum rheumatoid factor (RF)
    • Rheumatoid nodules
    • Radiographic evidence of RA
  • Other contributing history includes the following:
    • General malaise
    • Weakness
    • Fever of undetermined etiology
    • Weight loss
    • Myalgias
    • Tendonitis
    • Bursitis

Physical

  • Joint involvement is typically polyarticular and symmetrical, usually sparing the distal interphalangeal (DIP) joints. Joint involvement and inflammation is evinced by the following and is shown in the photo below:

    • Rheumatoid changes in the hand. Photograph by Dav...

      Rheumatoid changes in the hand. Photograph by David Effron, MD, FACEP.

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      Rheumatoid changes in the hand. Photograph by Dav...

      Rheumatoid changes in the hand. Photograph by David Effron, MD, FACEP.

    • Edema
    • Effusion
    • Warmth
    • Tenderness to palpation
    • Decreased range of motion
    • Joint destruction (a late finding)
    • Subcutaneous rheumatoid nodules (shown in the photo below), swan-neck deformities, boutonniere deformities, ulnar deviation of fingers at MCP joints (late findings)

    • Rheumatoid nodules at the elbow. Photograph by Da...

      Rheumatoid nodules at the elbow. Photograph by David Effron, MD, FACEP.

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      Rheumatoid nodules at the elbow. Photograph by Da...

      Rheumatoid nodules at the elbow. Photograph by David Effron, MD, FACEP.

    • Bursitis
  • Various inflammatory disorders of remote organ systems may be present and may contribute to the presenting problem. Organ systems that may be affected include the following:
    • Cardiac - Carditis, pericarditis
    • Pulmonary - Pleuritis, intrapulmonary nodules, interstitial fibrosis
    • Hepatic - Hepatitis
    • Ocular -Scleritis, episcleritis, dryness of the eyes
    • Vascular - Vasculitis
    • Skin - Subcutaneous nodules, ulcers
  • Rheumatoid arthritis is a diffuse systemic disease involving many areas of the body. The presenting complaint may be remote from a joint or may involve inflammatory symptoms at a joint.

Causes

  • The cause of rheumatoid arthritis (RA) has not been elucidated. Several possible associations have been described.
  • Associated factors may include the following:
    • Genetic predisposition
    • Female sex
    • Psychological stress
    • Immune response
    • Hormone interaction
    • Viral infection

More on Arthritis, Rheumatoid

Overview: Arthritis, Rheumatoid
Differential Diagnoses & Workup: Arthritis, Rheumatoid
Treatment & Medication: Arthritis, Rheumatoid
Follow-up: Arthritis, Rheumatoid
Multimedia: Arthritis, Rheumatoid
References
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Further Reading

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Keywords

rheumatoid arthritis, RA, arthritis deformans, arthritis nodosa, nodule, symptoms, treatment, causes, juvenile, autoimmune disease, nodose rheumatism, joint pain, joint deformity, morning stiffness, arthritis of the hand, positive serum rheumatoid factor, RF, rheumatoid nodules, subcutaneous rheumatoid nodules, joint stiffness, Swan-neck deformities, boutonniere deformities, ulnar deviation of fingers at metacarpophalangeal joints, seronegative

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Contributor Information and Disclosures

Author

Randall W King, MD, FACEP, Assistant Clinical Professor of Emergency Medicine, The University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center
Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Ohio State Medical Association, and Society for Academic Emergency Medicine
Disclosure: Challenger corporation None Other

Coauthor(s)

Richard Worthington, MD, Assistant Clinical Professor, Program Instructor, Department of Emergency Medicine, St Vincent Mercy Medical Center
Richard Worthington, MD is a member of the following medical societies: American College of Emergency Physicians, Ohio State Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gino A Farina, MD, FACEP, FAAEM, Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center
Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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