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The clinical features of Rheumatoid Arthritis (RA)

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By Grassi W, De Angelis R, Lamanna G, Cervini C • • May 5, 1998

Rheumatoid arthritis (RA) is a chronic inflammatory disease
characterized by progressive damage of synovial-lined joints
and variable extra-articular manifestations. Tendon and bursal
involvement are frequent and often clinically dominant in
early disease. RA can affect any joint, but it is usually
found in metacarpophalangeal, proximal interphalangeal and
metatarsophalangeal joints, as well as in the wrists and knee.

Articular and periarticular manifestations include joint
swelling and tenderness to palpation, with morning stiffness
and severe motion impairment in the involved joints. The
clinical presentation of RA varies, but an insidious onset of
pain with symmetric swelling of small joints is the most
frequent finding. RA onset is acute or subacute in about 25%
of patients, but its patterns of presentation also include
palindromic onset, monoarticular presentation (both slow and
acute forms), extra-articular synovitis (tenosynovitis,
bursitis), polymyalgic-like onset, and general symptoms
(malaise, fatigue, weight loss, fever). The palindromic onset
is characterized by recurrent episodes of oligoarthritis with
no residual radiologic damage, while the polymyalgic-like
onset may be clinically indistinguishable from polymyalgia
rheumatica in elderly subjects. RA is characteristically a
symmetric erosive disease. Although any joint, including the
cricoarytenoid joint, can be affected, the distal
interphalangeal, the sacroiliac, and the lumbar spine joints
are rarely involved. The clinical features of synovitis are
particularly apparent in the morning. Morning stiffness in and
around the joints, lasting at least 1 h before maximal
improvement is a typical sign of RA. It is a subjective sign
and the patient needs to be carefully informed as to the
difference between pain and stiffness. Morning stiffness
duration is related to disease activity. Hand involvement is
the typical early manifestation of rheumatoid arthritis.

Synovitis involving the metacarpophalangeal, proximal
interphalangeal and wrist joints causes a characteristic
tender swelling on palpation with early severe motion
impairment and no radiologic evidence of bone damage. Fatigue,
feveret, weight loss, and malaise are frequent clinical signs
which can be associated with variable manifestations of
extra-articular involvement such as rheumatoid nodules,
vasculitis, hematologic abnormalities, Felty's syndrome, and
visceral involvement. Although there is no laboratory test to
exclude or prove the diagnosis of rheumatoid arthritis,
several laboratory abnormalities can be detected. Abnormal
values of the tests for evaluation of systemic inflammation
are the most typical humoral features of RA. These include:
erythrocyte sedimentation rate, acute phase proteins and
plasma viscosity. Erythrocyte sedimentation rate and
C-reactive protein provide the best information about the
acute phase response. The C-reactive protein is strictly
correlated with clinical assessment and radiographic changes.

Plain film radiography is the standard investigation to assess
the extent of anatomic changes in rheumatoid arthritis
patients. The radiographic features of the hand joints in
early disease are characterized by soft tissue swelling and
mild juxtaarticular osteoporosis. In the the past 10 years,
ultrasonography has gained acceptance for studying joint,
tendon and bursal involvement in RA. It may improve the early
clinical assessment and the follow-up of these patients,
showing such details as synovial thickening even within finger
joints. Other imaging techniques, such as magnetic resonance,
computed tomography and scintigraphy may provide useful
information about both the features and the extent for
anatomic damage in selected rheumatoid arthritis patients. The
natural history of the disease is poorly defined; its clinical
course is fluctuating and the prognosis unpredictable. RA is
an epidemiologically relevant cause of disability. An adequate
early treatment of RA may alter the disease process.

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