Clinical Manifestations and Diagnosis

The onset and course of rheumatoid arthritis are particularly variable. Usually, fatigue, weight loss, and generalized aching and stiffness, especially on awakening in the morning, precedes localization of symptoms and the development of joint swelling. These symptoms at times develop explosively in one or more joints, but more often there is progression to multiple joint involvement. The disease may remit spontaneously in the first year or diminish in intensity, only to recur in the same or additional joints at intervals. The more troublesome cases usually continue to affect many joints with sustained inflammatory reactions for months or years. In these latter cases, marked bone and joint damage often develop, with drift of the ulna (outer bone of the forearm) and consequent deviation of the fingers, leading to lim ited function and instability. Signs of systemic involvement may also be seen, for example, nodules at the elbows, cutaneous degeneration at the fingertips (which appear as small, 1- to 2-millimeter infarcts in the nail fold) or at the elbow tip, pulmonary fibrosis, inflammation of the sac enclosing the heart, anemia, fever, rash and peripheral ulcers in the lower limbs, disease of the nervous system, and wrist weakness occasioned by the carpal tunnel syndrome. In addition, there is usually a gradual weight loss as well as the loss of muscle volume and power.

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