Clinical Presentation and Diagnosis of RA General

• About 60% of patients develop symptoms gradually over several weeks to months.

• Patients may present with systemic findings, joint findings, or both. Symptoms

• Nonspecific systemic symptoms may include fatigue, weakness, anorexia, and diffuse musculoskeletal pain.

• Patients complain of pain in involved joints and prolonged morning joint stiffness. Signs

• The metacarpophalangeal (MCP), proximal interphalangeal (PIP), metatarsophalangeal (MTP), and wrist joints are involved frequently.

• Joint involvement is usually symmetric.

• There is often limited joint function.

• Signs of joint inflammation are present (tenderness, warmth, swelling, and erythema).

• Low-grade fever may be present.

• Extraarticular manifestations:

• Skin: Subcutaneous nodules

• Ocular: Keratoconjunctivitis sicca, scleritis

• Pulmonary: Interstitial fibrosis, pulmonary nodules, pleuritis, pleural effusions

• Vasculitis: ischemic ulcers, skin lesions, leukocytoclastic vasculitis

• Neurologic: Peripheral neuropathy, Felty's syndrome

• Hematologic: Anemia, thrombocytosis Laboratory Tests

• Positive rheumatoid factor (the test is negative in up to 30% of patients)

• Elevated ESR (Westergren ESR: greater than 20 mm/h in men; greater than 30 mm/h in women)

• Elevated C-reactive protein (CRP) (greater than 0.7 mg/dL or 7 mg/L)

• CBC: Slight elevation in WBC count with a normal differential; slight anemia; thrombocytosis

• Positive anti-CCP antibodies Other Diagnostic Tests

• Synovial fluid analysis: Straw colored, slightly cloudy, WBC 5 to 25 x 10 /mm (5-25 x 109/L), no bacterial growth if cultured.

• Joint x-rays: To establish baseline and evaluate joint damage.

• MRI: May detect erosions earlier in the course of disease than x-rays but is not required for diagnosis.

Several clinical features of RA are associated with a worse long-term prognosis. The presence of these poor prognostic features should be considered at the time initial treatment decisions are made; more aggressive treatment may be warranted if these features are present. The most clinically important features associated with poor long-term outcomes include: (a) functional limitation (defined by use of standard measurement scales such as the Health Assessment Questionnaire [HAQ] score); (b) extra-articular disease; (c) positive rheumatoid factor; (d) positive anti-CCP antibodies; and/or (e) bony erosions by radiography.

Diagnostic criteria for JIA include: (a) age less than 16 years at disease onset; (b) arthritis in one or more joints for more than 6 weeks; (c) exclusion of other types of arthritis. JIA can be divided into three types:

1. Systemic (approximately 10% of cases) : occurs equally in girls and boys. There are characteristic fever spikes twice daily (greater than 38.3°C or 101°F) and the presence of a pale, pink, transient rash. The peak onset is between ages 1 and 6 years.

2. Polyarticular (approximately 40% of cases): more likely to affect girls than boys (3:1). Arthritis is present in five or more joints. The disorder resembles adult RA more than the other types of JIA.

3. Pauciarticular (approximately 50% of cases): more likely to affect girls than boys (5:1). Uveitis is more likely to be present. Arthritis is present in four or fewer joints. Categories are further divided into early onset and late onset. Early onset is more likely to occur in girls, whereas late onset is more common in boys.16

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