Rheumatoid Arthritis

Rheumatoid Arthritis (R.A.)

     Rheumatoid Arthritis is an inflammatory chronic disease that affects mostly joints and at times internal organs. Genetic predisposition and environmental factors play an important role. It is of worldwide distribution and affects all ethnic groups. It affects females twice as much as it does males. The peak incidence occurs between the fourth and the sixth decades. Although the cause of R.A. remains unclear in the mainstream literature, the possibility of bacterial, mycoplasma or viral infections is relevant, since all these pathogens can induce chronic arthritis in animal models or humans. Furthermore, the deposition of bacterial products in synovial tissue as well as chronic infections have been shown to be responsible for chronic synovial inflammation. Examples of these infections include those caused by such microorganisms as Borrelia burgdorferi that causes Lyme disease, Parvo virus causing inflammatory arthritis, and Rubella virus producing chronic polyarthritis.

     Several research groups as well as Dr. Franco have shown the association of mycoplasma infection with several inflammatory arthropathies.

     Although the clinical picture of R.A. is variable, usually patients present with a symmetrical polyarthritis affecting large, medium and small joints and occasionally the cervical spine. Extra-articular manifestations may involve the skin with the formation of nodules and or vasculitis. The respiratory tract may be involved with interstitial pulmonary  fibrosis that usually affects the bases of the lungs, lung nodules, and pleurisy. Likewise, the lining of the heart may be involved; the heart muscle itself and valves can also be affected. The salivary glands produce less secretion in Sjogren's associated with R.A. Neurological complications may affect the peripheral nerves or the spinal cord due to instability of the cervical spine caused by involvement of the cervical vertebrae. Anemia is not uncommon and correlates with disease activity. Elevated platelet counts are found in severe cases and they correlate with inflamtion. . Low white count is rarely encountered. Finally, renal involvement is very infrequent and usually caused as a toxic side effect of medications.

The following chart shows the diagnostic criteria for the classification of Rheumatoid Arthritis.

The American Rheumatism Association 1987 
Revised Criteria for the Classification of Rheumatoid Arthritis*

1. Morning stiffness Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement
2. Arthritis of three or more joint areas At least three joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician. The 14 possible areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints
3. Arthritis of hand joints At least one area swollen (as defined above) in a wrist, MCP, or PIP joint
4. Symmetric arthritis Simultaneous involvement of the same joint areas (as defined in 2) on both sides of the body (bilateral movement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry)
5. Rheumatoid nodules Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxtaarticular regions, observed by a physician.
6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects
7. Radiographic changes Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify)
* For classification purposes, a patient shall be said to have rheumatoid arthritis if he/she has satisfied at least four of these seven criteria. Criteria 1 through 4 must have been present for at least 6 weeks. Patients with two clinical diagnoses are not excluded. Designation as classic, definite, or probable rheumatoid arthritis is not to be made.
Reprinted from Arnett FC, Edworthy, SM, Bloch DA, et all The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 31:315-342, 1988, with permission of the American College of Rheumatology.




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     *The information in this website is not intended to replace a rheumatology textbook nor be a complete update of the rheumatology scientific literature.  It should not be misconstrued as personal medical advice.  Rather, it portrays Dr. Al Robert Franco's interests in the field of rheumatology, namely, the interrelationship between infections and rheumatic diseases and how this applies to the treatment of arthritis.