To the general public rheumatoid arthritis (RA) is probably the best known autoimmune disorder. Affecting three times as many women as men, it is a chronic, often relapsing disease that may involve any combination of joints. In advanced cases it is a deforming, often severely disabling and potentially life-threatening condition. As in the case of lupus, an inherited susceptibility is believed to be a factor in its development. The possible contributing roles of viral infection, stress, and hormonal factors remain to be elucidated. The initial autoallergic (autoimmunologic) site of attack involves the synovium, the membranelike tissue covering of the joints.
In most cases the symptoms of rheumatoid arthritis first appear between the ages of thirty-five and forty-five. Small, medium, or large joints, such as the fingers, wrists, elbows, knees, and hips, may be involved alone or in any combination. Joint involvement is often symmetrical, meaning that, for example, both knees or both wrists are usually involved simultaneously.
Early in the course of the disease, sufferers usually complain only of low-grade fever, fatigue, weight loss, glandular swelling, and morning stiffness in their joints. Thereafter, however, symptoms progress either slowly or rapidly. In long-standing cases, muscular contractures (severe stiffening and irreversible contractions of the muscles) may occur and lead to all kinds of characteristic skeletal deformities. Some of these deformities have been given descriptive names because of their striking physical appearance for example, the "swan neck" or "cock-up toes" deformities of the hands and feet.
In addition to joint problems, patients with rheumatoid arthritis may suffer with inflammation of the outer lining tissues of the lungs and heart (pleuritis and pericarditis, respectively); nerve, eye, and blood vessel problems; and the development of skin nodules and ulcerations.
The diagnosis of rheumatoid arthritis requires a thorough history and physical examination, looking for the presence of at least several of the above manifestations. The rheumatoid factor test is the major blood-screening examination for this condition. A negative test (that is, one in which the rheumatoid factor is not found) does not exclude the diagnosis, however, since it may be absent in as many as 20 percent of those who fit the other criteria for rheumatoid arthritis. Nonetheless, it is an excellent screening examination. Questionable cases require the use of other, often more sophisticated immunologic blood testing. X-ray examination, looking for the destructive changes typical of RA, are also helpful.
The course of the disease is unpredictable. As many as 20 percent of patients are fortunate enough to experience a complete disappearance of the problem or only mild, occasional flare-ups of the condition. On the other hand, approximately 10 percent suffer progressive crippling. The vast majority of persons with the condition fall somewhere in between these two extremes.
For persons with mild to moderate disease, rest, physical therapy, and the use of high-dose aspirin or other nonsteroidal antiinflammatory agents (such as Motrin, Naprosyn, or Indocin) may be sufficient to control symptoms and improve the quality of life. For more resistant cases, occasional use of low doses of oral corticosteroids (prednisone) and the injection of corticosteroids directly into affected joints may provide dramatic relief for prolonged periods of time. A number of other potent systemic agents are available in the event that these measures prove inadequate. For advanced cases, treatment is challenging, and management requires an interdisciplinary approach that ideally involves a team of rheumatologists, dermatologists, physical therapists, occupational therapists, psychologists, and surgeons. For more information contact the Arthritis Foundation, 1314 Spring Street, N.W, Atlanta, Georgia 30309.
