CASE REPORT

RHEUMATOID ARTHRITIS

Present by
Nurul Diyana Bt. Azizan C111 12 859
Muhammad Syahir B. Tajuddin C111 12 865
Adviser :
dr. Erwin Tinambunan
Identity

Name : Mrs. N
Gender : Female
Date of birth : 53 y.o.
Address : Makassar
Occupation : Farmer
Religion : Islam
Ethnicity : Ternate
History Taking
Chief complaint: Multiple joint pain

Joint pain has been being experienced since 2 years ago, worsened within the last
month and accompanied with swelling and redness. The pain is felt continously,
worsened with walking, and not spreading to other area. The pain is felt
dominantly on the wrists, knuckles, toe knuckles, ankles, and knees of both left
and right side symmetrically. Pain joint initially began on the knuckles of both
fingers. Weeks later the pain was also felt on wrists, knees, and toe knuckles.
There is joint stiffness in the morning with duration of approximately more than
an hour. Fever is present, no chills. Patient also had been experiencing weight
loss since 2 years ago approximately about 10 kgs in total. There is history of
consuming medications (3 types) that is not prescribed by physician in the last 2
years, medication names are unknown. The pain was relieved with these
medications. The last time she took these medications was 6 months ago.
History taking
There is no history of abnormal bleeding.
There is no history of black watery stool.
There is no history of hair fallout, mouth
ulcers, and facial rash. There is no nausea
and vomitting. Urination is within normal
limit, no history of dark urine. Defecation is
regular, no history of black watery stool.
Medical history
There is no history of high blood uric acid.
There is no history of high blood pressure.
There is no history of diabetes mellitus.
There is no history of lung tuberculosis.
There is no history of high blood cholesterol.
There is no history of stroke.
There is no history of malignancy.
There are no similar symptoms and disease
in the family.
Physical examination
General Status : Moderate illness
Nutritional status : Well nourished (155 cm/45 kg), BMI 18,7
Consciousness : Compos mentis GCS 15 (E4M6V5)

Blood Pressure : 120/80 mmHg

Heart Rate : 92 bpm
Respiration Rate : 22 rpm (Thoracoabdominal)
Temperature : 36,6C
VAS : 4/10
Physical examination

Head : Within normal limit (WNL), long black hair not easy to
remove
Eyes : Anemic conjunctiva (-), icteric sclerae (-),
movement WNL
Pupil : Isochoric, 2mm/2mm
Ear : Tophus (-)
Nose : WNL
Mouth : Lips, teeth and gums WNL, oral ulcer (-)
Tonsil T1-T1 not hyperrhemic
Pharnyx not hyperrhemic
Tongue WNL (no dirty tongue)
Physical examination
Neck : Lymphonode enlargement (-)
Thyroid gland WNL
JVP R+2 cmH20 (300)
Carotid artery WNL (no bruit)
Neck rigidity (-)
Thorax
Inspection : Symmetrical movement, visible mass (-),
mammary glands WNL
Palpation : Crepitation (-), tenderness (-), palpable mass (-)
Vocal fremitus is WNL
Apex cordis palpable
on 5th ICS of midaxillary line sinistra
Percussion : Sonor, hepatopulmonary margin on 6th ICS
dextra, migrated 1 ICS inferiorly in deep breath
Auscultation : Vesicular breath sound
No rales or wheezing
Heart sound S1/S2, regular
No murmur
Physical examination
Abdomen
Inspection : Flat, visible mass (-)
Auscultation : Peristaltic (+) 6 times/minutes
Palpation : Tenderness (-), palpable mass (-)
Percussion : Tympanic

Gait : Antalgic gait

Arm :
-Shoulder joint D&S : ROM WNL in both shoulder
Active resisted internal rotation test (-)
Active resisted external rotaion test (-)
- Elbow joint D&S : WNL
- Wrist joint:
- Dextra : pain (+), swelling (+), calor (+), rubor(+),
tenderness (+), limited passive and active ROM
due to pain
- Sinistra : pain (+), swelling (+), calor (+), rubor (+), tenderness
(+), limited passive and active ROM due to pain
Physical examination
-MCP & PIP II, III, IV, V:
- Dextra : pain (+), swelling (+), calor (+),
rubor (+), tenderness (+), limited
passive and active ROM due to pain
- Sinistra : pain (+), swelling (+), calor (+),
rubor (+), tenderness (+), limited
passive and active ROM due to pain

-DIP Dextra &Sinistra : Within Normal Limit

Physical examination
Legs:
- Hip joint : WNL in both hips
- Knee joint:
Dextra & Sinistra: rubor (+), swelling (+), calor (+),
tenderness (+), crepitation (-), limited
active and passive ROM due to pain
- Ankle joint:
Dextra & Sinistra: rubor (+), swelling (+), calor (+),
tenderness (+), limited active and
passive ROM due to pain
Legs:
- MTP & PIP II, III, IV, V:
- Dextra : pain (+), swelling (+), calor (+),
rubor (+), tenderness (+), limited passive and
active ROM due to pain
- Sinistra : pain (+), swelling (+), calor (+),
rubor (+), tenderness (+), limited passive and
active ROM due to pain
-DIP: Within Normal Limit

Spine: Within Normal Limit

Laboratorium :
complete blood count
TEST RESULT NORMAL VALUE
WBC 5.500 /uL 4 10 x 103 /uL
RBC 4,8 x 106 /uL 4,50 6,50 x 106 /uL
HBG 14,1 g/dl 14 18 /dl
HCT 42,3 % 40 54 %
MCV 96 80 100
MCH 30 pg 27 32 pg
PLT 144 x 103 /uL 150 400 x 103 /uL
PCT 0,19 % 0,15 0,50 %
NEUT 76,3 % 52 75 %
LYMPH 17,1 % 20 40 %
MONO 5,7x103 /uL 2 8 x 103 /uL
EOS 0,6 x103 /uL 1,00 3,00 x103 /uL
BASO 0,02 x103 /uL 0,00 0,10 x103 /uL
>90/>90 ( 1st hour , 2nd
ESR <20 mm/hour
hour)
Laboratorium result
Test Result Normal value
Ureum 27 mg/dl 10-50 mg/dl

Creatinin 0,46 mg/dl M(<1,3);F(<1,1)

mg/dl
SGOT 27 U/l <38 U/l

SGPT 9 U/l <41 U/l

Natrium 145 mmol/l 136-145 mmol/l

Kalium 3,7 mmol/l 3,5-5,1 mmol/l

Chloride 100 mmol/l 97-111 mmol/l

serology
Test Result Normal
value
Serum RF 41,2 IU/ml <30 IU/ml
ASTO 61 IU/ml <200 IU/ml
CRP 5,2 mg/l <5 mg/l
LE cell Positive Negative
 Diagnosis
Problems Management and
Planning
1. Rheumatoid arthritis Management:
Based on Sulphasalazine 500 mg/12 hours/oral
-Joint involvement of PIP II, III, IV, V D et S, Methylprednisolone 4 mg/8 hours/oral
MCP II, III, IV, V D et S, wrist joints D et S,
knee joints D et S > 10 joints (> 10 joints) Planning:
score 5 Triamcinolone acetonide 40 mg :
-RF 41,2 IU/mL (low positive) score 2 Lidocaine 2% = 2 : 1 per
-CRP 5,2 mg/l, ESR >90/>90 mm/hour intraarticular
score 1 Arthrocentesis
-Duration of symptoms 2 years ( 6 weeks) Wrist x-ray D et S AP + Lat
score 1 Manus x-ray D et S AP + Lat
Knee x-ray D et S AP + Lat
Total score = 9 Chest x-ray PA
Anti-CCP
CBC every 2 weeks for the first 3
months, then every 3 months
DISCUSSION
DEFINITION
Rheumatoid arthritis is an autoimmune disease in
which the normal immune response is directed
against an individual's own tissue, including the
joints, tendons, and bones, resulting in inflammation
and destruction of these tissues.

Characterized by persistent inflammatory synovitis

leading to cartilage damage, bone erosions, joint
deformity and disability.
ANATOMY
Articular/hyaline
cartilage
-acts as a shock
absorber
- allows for friction-
free movement
- not innervated!

Synovial
membrane/synoviu
m
-secretes synovial
fluid
-nourishes cartilage
-cushions the bones
ETIOLOGY
Genetic (HLA-DRB1)
Sex hormone : Estrogen and
progesteron can suppress Th1 activity
Persistent infection of several
microbiologic agents (e.g. EBV,
mycoplasma)
Involvement heat shock protein leading
to molecular mimicry
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
CLINICAL
MANIFESTATION
 Articular
Manifestation

Pain and swelling in

affected joint
aggravated by
movement is the most
common symptom.
Typically simmetric
pattern
Morning stiffness 1
hr
Joints involved 10
joints
PIP Swelling Ulnar Deviation, MCP Swelling, Left
Wrist Swelling
 Boutonniere Deformity
&
Swan Neck Deformity

Figure 68.7 Boutonni&#232;re and swan-neck deformities. The boutonni&#232;re deformity - PIP flexion and DIP
hyperextension - results from relaxation of the central slip, with 'buttonholing' of the PIP joint between the lateral bands. The
swan-neck deformity - MCP flexion, PIP hyperextension and DIP flexion - may be mobile, snapping or fixed. Its pathogenesis
may be related primarily to PIP or MCP involvement. Combinations of MCP and PIP involvement are less frequent. (Adapted
with permission from Hastings DE and Welsh RP. Surgical reconstruction of the rheumatoid hand. Toronto: Orthopaedic
Medical Management Corporation; 1979.)
EXTRA ARTICULAR
MANIFESTATION
Present in 30-40%
May occur prior to arthritis
Patients that are more likely to get are:
High titres of RF/ anti-CCP
HLA DR4+
Male
Early onset disability
History of smoking
 EXTRA ARTICULAR INVOLVEMENT

Constitutional symptoms ( most common) Respiratory- pleural effusion, pneumonitis ,

pleuro-pulmonary nodules

Rheumatoid nodules(30%) CVS-asymptomatic pericarditis , pericardial

effusion, cardiomyopathy

Hematological
Rheumatoid vasculitis- mononeuritis
normocytic normochromic anemia
multiplex, cutaneous ulceration, digital
leucocytosis /leucopenia
gangrene, visceral infarction
thrombocytosis

CNS- peripheral neuropathy, cord-

Feltys syndrome- compression from atlantoaxial/midcervical
Chronic nodular Rheumatoid spine subluxation, entrapment neuropathies
Arthritis
Spleenomegaly EYE- kerato-conjunctivitis sicca, episcleritis,
Neutropenia scleritis
Staging of Rheumatoid Arthritis
RADIOLOGICAL IMAGING
Conventional x-ray
Early sign: periarticular soft-tissue swelling with a
fusiform appearance, juxta-articular osteopenia
Widening joint spaces narrowing joint spaces
Marginal erosion
Subluxation, malalignment, deviation
Tendon rupture
Late stage: fusion or joint ankylosis
End stage: extensive erosions resorption and tapering
of the ends of the bones
Complication of therapy: generalized osteoporosis,
avascular necrosis
Ultrasonography
Joint effusion: hypoechoic
Hypertrophic synovium: echogenic
Rheumatoid nodules: fluid-filled round
cavities with sharp borders
Bone erosions: irregularities in the
hyperechoic cortex
Magnetic Ressonance Imaging
Good delineation of soft-
tissue changes
Superior to radiography in
the early detection of bone
erosions, cartilaginous
defects, and osseous
erosions
Inflammed synovial lining:
low signal intensity on T2-
weighted images
Tenosynovitis resulting from
inflammation: highsignal-
intensity fluid on T2-
weighted sequences
Amplitude Color Doppler
Higher sensitivity to flow evaluating the manifestation of
hyperemia in the inflammatory joint tissues
 LABORATORY FINDINGS :
RHEUMATOID FACTOR
Antibodies directed against Normal value: < 15 IU/mL
the Fc fragment of IgG or < 1:80
Heterogenous, produced by High RF titres indicate more
B-cell, usually composed of severe disease, hence a
IgM (in most assays poorer prognosis
detected as only IgM) Low levels of RF can even
Can be found in various be found in healthy patients
autoimmune disease, (1-5%)
connective-tissue disease, False positive: SLE,
e.g. RA, SLE, polymyositis polymyositis, Sjorgens
RF results are positive in syndrome, scleroderma, TB,
approximately 75% of syphilis, viral hepatitis,
patients with RA influenza
 Laboratory Findings:
Anti-CCP
Anti-cyclic-cytrullinated- Better specificity than RF
peptide, antibody against (95%), also presence in
citrullinated proteins in early stage
synovial membrane Associated with the
damaged by inflammation presence of HLA-DR4
Associated with greater alleles in patients with RA
inflammatory activity, Normal value: < 20 u/mL
poorer radiologic
outcome, and higher
frequency of extra-
articular manifestations
DIAGNOSIS
DIAGNOSIS
Disease Activity Score
DAS28
Measure of disease activity in rheumatoid arthritis
To calculate the DAS28:
1. Count the number of swollen joints (out of the 28)
2. Count the number of tender joints (out of the 28)
3. Take blood to measure the erythrocyte
sedimentation rate (ESR) or C reactive protein (CRP)
4. Ask the patient to make a global assessment of
health' (indicated by marking a 10 cm line between
very good and very bad)
. These results are then fed into a complex
mathematical formula to produce the overall disease
activity score
DAS28:
Formula & Interpretation

***Tender28 = tenderness on the 28 joints

Swollen28 = swelling on the 28 joints
ESR = ESR in the first hour
GH = patients assessment of general health
DIFFERENTIAL
DIAGNOSIS
Symptoms
Osteoarthritis
Manus
Rheumatoid
Arthtritis
Gout
Arthtritis
SLE Patient
Morning
< 30 minutes > 30 minutes - - > 1 hour
stiffness

Systemic
reaction (fever,
- + - + +
malaise,
weight loss)

Most common >

Age 30-80 years old 53 years old
50 years old
Herbenden/Bouc Symmetrical,
Symetrical, small Unilateral
Arthritis hard nodes, Polyarthritis small joints
joint (MCP, PIP) (MTP-1)
CMC involvement
- ESR, RF/Anti CCP MSU, Blood ESR, RF
Lab work hiperurisemia disorder, ANA,
LE cell
Radiologic Osteophyte, Juxta-articular Subcortical
abnormalities narrowing joint erosions, periarticular cyst, erosion
space osteopenia, swollen -
soft tissues
TREATMENT

2015 American College of Rheumatology Guideline for the

treatment of rheumatoid arthritis
Treatment modalities:
NSAIDs
Glucocorticoids
Traditional Disease-Modifying
Antirheumatic Drugs (traditional
DMARDs, herein referred to as DMARDs)
Biologic DMARDs (herein referred to as
biologic agents)
Immunosupressive therapy
Surgery
NSAIDs
(Nonsteroidal Antiinflammatory Drugs)

Coxibs, for symptoms control

Reduce pain and swelling by inhibiting
COX
Do not alter course of the disease
Chronic use should be minimized
Most common side effect related to GI
tract
 Glucocorticoids

Can be administered systemically or intraarticularly

Indications:
1. For treatment of rheumatoid flares
2. For extraarticular RA like rheumatoid vasculitis and
interstitial lung disease
3. As bridge therapy for 6-8 weeks before the action of
DMARDs begin
4. Maintainence dose of 10 mg or less of predinisolone
daily in patients with active RA
5. Sometimes in pregnancy when other DMARDs
cannot be used.
 DMARDs
Drugs that actually alter the disease
course
Should be used as soon as diagnosis is
made
Appearance of benefit delayed for weeks
to months
NSAIDS must be continued with them until
true remission is achieved
Induction of true remission is unusual
 DMARDs: Agents

Commonly used Less commonly

used
Methotrexate Chloroquine

Hydroxychloroquine Gold (parenteral and oral)

Sulphasalazine Cyclosporine-A

Leflunomide D-penicillamine/Bucillamine

Minocycline/Doxycycline
Levamisole

Azathioprine, Cyclophosphamide,
Chlorambucil
 DMARDs:
Clinical Information
Mechanism of Onset of
Name Dose Side effects Monitoring
Action action
Hydroxycloroquine 200 mg twice Inhibit: cytokine Skin Fundoscopy & 2-4 months
daily x 3 secretion, pigmentation , perimetry yearly
lisosomal retinopathy,
months, then enzyme and nausea,
once daily macrophage psychosis,
functions myopathy

Methotrexate 7.5-25 mg Dihydrofolate GI upset, Blood counts, 1-2 months

once a week reductase hepatotoxicity, LFT 6-8 weekly,
inhibitor, inhibits bone marrow Chest x-ray
orally, SC, or chemotaxis, annually,
suppression,
IM antiinflammatory pulmonary urea/creatinine 3
effect by inducing monthly; liver
fibrosis
adenosine biopsy
release

Sulphasalazin 2 gm daily Inhibit: B cell Rash, myelo- Blood counts, 1-2 months
e p.o. response, suppression, LFT 6-8
angiogenesis reduced sperm
count weekly

Leflunomide Loading 100 mg Inhibits Nausea, LFT 6-8 1-2 months

daily x 3 days, pyrimidine diarrhoea, weekly
then 10-20 mg synthesis alopecia,
daily p.o. hepatotoxicity
 Immunosuppresive
Therapy
Agent Usual Mechanism of Side effects Onset of action
dose/route action
Azathioprine 50-150 mg Inhibits DNA GI side effects, 2-3 months
orally synthesis myelosuppressio
n, infection

Cyclosporin-A 3-5 mg/kg/day Inhibits Nephrotoxic , 2-4 months

synthesis of IL-2 hypertension,
and other T-cell hyperkalemia
cytokines
Cyclophosphamid 50 -150 mg Interferes DNA Myelosuppressio 1-6 months
e orally replication by n, gonadal
forming DNA toxicity,
cross-linkage, hemorrhagic
cytotoxic effects cystitis, bladder
on lymphocytes cancer
 Biologic Agents

Anti TNF agents: Infliximab, Etanercept,

Adalimumab
IL-1 receptor antagonist: Anakinra
IL-6 receptor antagonist: Tocilizumab
Anti-CD20 antibody: Rituximab
T-cell costimulatory inhibitor: Abatacept
Biologic Agents
Biologic Agents
2015 American College of Rheumatology Guideline for the
treatment of rheumatoid arthritis
 Surgery
Indications:
Severe pain associated with extensive joint damage
Severe limitation of ROM or function
Tendon rupture

Surgeries:
Synovectony
Tenosynovectomy
Tendon realignment
Reconstructive surgery or arthroplasty
Arthrodesis
ACR 2015:
Algorithm
of treatment
[Early RA]
ACR 2015:
Algorithm
of treatment
[Established RA]
Remission Criteria
Complication

Joint disability, pain, anf deformity

Anemia
Infections
GI problems
Osteoporosis
Heart disease
Sjgren'ssyndrome
Feltys syndrome
Malignancy
Prognosis
Poor prognosis predictor at early stage: low
functional score, low social-economy status,
poor educated, family history of RA, multiple
joints, high ESR or SCRP at early onset,
positive RD or anti-CCP, radiological changes
at early onset, extraarticular manifestations
Increase of mortality in first 8-13 years after
diagnosis
Long-term use of DMARDs may reduce
mortality rate