Rheumatoid arthritis is a systemic disorder and, therefore, does not involve only the joints. It can present with generalized malaise, low grade fever and significant morning stiffness. The stiffness generally lasts more than one hour, and with severe inflammation may last throughout the day. The presenting features may vary from patient to patient. It may be an "explosive" onset with severe involvement, low grade fever, swollen joints, and diffuse myalgias. The disease also may start more insidiously, developing over several weeks to months. At the onset some of these symptoms may be episodic with several days of joint involvement followed by periods of remission.

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The physical findings in rheumatoid arthritis are generally related to the joint involvement. Early on, there may be joint capsular swelling and tenderness over the involved joints. The joints involved are primarily the large knuckles of the hands and the proximal joints of the fingers. Those joints that are nearest to the fingernail beds (the distal interphalangeal joints) are rarely involved in rheumatoid arthritis. The wrists are also involved particularly over the outside bony prominence near the fifth or pinky finger (also known as the ulnar styloid). This is a common area of involvement. In chronic rheumatoid arthritis, the inflammation leads to destruction of the normal joint and leads to a variety of deformities involving the hands which diminish grip strength and flexibility of the fingers. Other findings include small hard nodules which are usually nonpainful, but clearly palpable. These occur primarily over the elbows, in front of the knees, or in areas where there is increased physical pressure (such as the back part of the ankle over the Achilles tendon). Joint swelling and fluid accumulation within a joint can often be detected particularly in the knees where joint aspiration may be necessary for diagnosis.

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The complete blood count may show a low grade anemia. Generally a hematocrit of less than 30% requires a workup for gastrointestinal blood loss. A chemistry panel is generally normal in rheumatoid arthritis. The urinalysis is generally normal. A rheumatoid factor is positive in 80% of patients at presentation with the majority converting to a seropositive result within one year after diagnosis. An antinuclear antibody (ANA) is seen in about 30% of patients with rheumatoid arthritis. Other antibodies that can be seen with rheumatoid arthritis are the SSA (Ro)/SSB (La) (Sjogren's antibodies). In patients who have Felty's syndrome, a subset of rheumatoid arthritis, a low white blood cell count and thrombocytopenia can be seen (see under diagnosis for more information on Felty's syndrome). A chest x-ray is helpful to rule out pleural involvement with a thickened pleural lining of the lung or chest cavity (pleural thickening) or small pleural effusions (fluid). An x-ray of the cervical spine in long-standing rheumatoid arthritis patients is necessary to rule out the possibility of destruction of the first vertebra (at C1) as it relates to the second cervical vertebra (at C2).

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The diagnosis of rheumatoid arthritis is presently under scrutiny by the American College of Rheumatology. In 1987 revised criteria for the classification of rheumatoid arthritis was published and the following seven criteria are listed below:

1. Morning stiffness lasting at least one hour.
2. Soft tissue swelling (arthritis) of three or more joint areas observed by a physician.
3. Arthritis of the proximal interphalangeal joint, metacarpal phalangeal joint or wrist joints.
4. Symmetric arthritis.
5. Subcutaneous nodules.
6. Positive test for rheumatoid factor.
7. Radiographic erosions or periarticular osteopenia in hands or wrist joints.

The presence of at least four or more of these criteria demonstrated at least a 92% sensitivity and an 89% specificity for rheumatoid arthritis when compared to controlled subjects. The diagnosis in large part is a clinical one which requires that the above symptoms including symmetric arthritis are present for at least a six week period. Felty's syndrome occurs in a subset of rheumatoid arthritis patients and is characterized by lymphadenopathy (lymph node enlargement), leukopenia (decreased WBCs), thrombocytopenia (decreased platelets), and splenomegaly (enlarged spleen).

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The treatment of rheumatoid arthritis has recently changed with the addition of newer disease modifying agents. Many of these agents can be further studied on this web site (see original articles on Reversing the Pyramid, Arava, TNF inhibitors, Enbrel and Remicade). Overall the treatment should be modified to the patient's needs. The long-term objective is to maintain functional capacity of involved joints and prevent and/or treat systemic complications. Long-term studies clearly show the beneficial effect of methotrexate. It has an acceptable safety profile. Combination therapies such as the use of methotrexate with sulfasalazine and Plaquenil or methotrexate and Arava as well as methotrexate and Remicade have been studied with positive results. The antibiotic minocycline has been shown to have mild to moderate clinical benefit in some rheumatoid patients and can be tried with caution.

Joel Rutstein M.D.
Rodolfo Molina, M.D.