What are the most common extra articular manifestations of Rheumatoid Arthritis?

Rheumatoid arthritis is a condition that can reduce the quality of life if untreated. It can also cause extra articular manifestations that can be life-threatening. However, some medications that can help slow and even stop the progression of this disease.

This article covers basic information on rheumatoid arthritis, and common extra articular manifestations rheumatoid arthritis patients should be aware of.

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune inflammatory disease in which your immune system mistakenly attacks healthy cells in your body. This disease affects the joints, usually the knees, hands, and wrists. However, it can also affect tissues in other parts of the body and, if left untreated, can damage the heart, lungs, and eyes.

Joints affected by rheumatoid arthritis become inflamed, and as a result, the joint tissue becomes damaged. This then causes chronic pain, lack of balance or unsteadiness, and even deformity of the joint.

What are the causes of rheumatoid arthritis?

Although we know that rheumatoid arthritis results from one's immune system attacking healthy tissue, the specific reason this happens is unknown.

For people with rheumatoid arthritis, their immune systems activate antibodies to attack tissue lining in the joints. This causes the lining cells, also known as synovial cells, to divide, causing inflammation. Additionally, chemicals released during this process can damage cartilage, ligaments, tendons, and bones in the area.

What are the risk factors for rheumatoid arthritis?

Rheumatoid arthritis risk factors include:

• Age - The risk of developing rheumatoid arthritis increases with age
• Sex - Females are two to three times more likely to develop this disease than males
• Genetics - Those born with HLA class II genotypes have an increased risk of developing this condition. The risk is higher when individuals with these genes are overweight or smoke
• History of live births - Women who have never given birth may be more at risk of developing this condition than those who have given birth
• Early exposure to smoking - Children who had mothers who smoked have twice the risk of developing this disease when they are adults
• Smoking - Children who had mothers who smoked have twice the risk of developing this disease when they are adults
• Obesity - Individuals who are obese are at a greater risk of rheumatoid arthritis
• Diet choices - High intake of sugar, sodium, red meat, and iron is linked to increased risk of this condition

Is rheumatoid arthritis hereditary?

No, rheumatoid arthritis is not considered a hereditary condition. However, it does seem to run in some families. This could be due to environmental and lifestyle factors in addition to genes. It could also be a combination of all these factors.

What are the symptoms of rheumatoid arthritis?

Signs and symptoms of rheumatoid arthritis include:

• Pain and/or stiffness in more than one joint. Stiffness worsens in the mornings and/or after inactivity
• Swelling and/or tenderness in more than one joint
• Similar symptoms both sides of the body, for example, in both hands
• Fatigue
• Weakness
• Weight loss
• Fever

There are times when rheumatoid arthritis symptoms can get better (remission) or worse (flares).

What are the early signs of rheumatoid arthritis?

Early signs of rheumatoid arthritis include pain or tenderness in small joints such as those in your fingers. However, it is not uncommon to have pain in larger joints such as your shoulder or knee. You must recognise the early signs as early treatment will help to prevent permanent joint damage.

What are the extra articular manifestations of rheumatoid arthritis?

Besides the symptoms mentioned above that mostly affect the joints, rheumatoid arthritis can also affect other organ systems. This is referred to as extra-articular disease.

• Rheumatoid nodules - Nodules happen in 20% to 30% of seropositive patients. They are usually on extensor surfaces of elbows and arms. However, they can also develop at pressure points of the knees and feet. The eyes, heart, and lungs can also be affected, although this is very uncommon.
• Cardiopulmonary disease - Pulmonary manifestations of rheumatoid arthritis include intrapulmonary nodules, diffuse interstitial fibrosis, and pleurisy with/without effusion. These conditions result in reduced lung capacity.
• Atherosclerosis - this cardiovascular manifestation is one of the most common in rheumatoid arthritis patients. Fats, and cholesterol clog the artery walls, causing plaque that narrow arteries and block blood flow. Chronic inflammation due to rheumatoid arthritis can lead to atherosclerosis.
• Eye diseases - Sicca or dry eyes are common issues. Episcleritis, which is the inflammation of the episclera, can also develop. Rheumatoid arthritis patients with episcleritis may have eyes that look very red and even painful. Keratoconjunctivitis of Sjogren’s syndrome is also a common extra articular manifestation.
• Sjogren’s syndrome - This is an autoimmune condition affecting the salivary and lacrimal glands. Symptoms of Sjogren’s syndrome include dry eyes, dry mouth, dental decay, fatigue, and joint pain. It can lead to lung, kidney, blood, nervous system, and gynaecologic diseases if not treated.
• Rheumatoid vasculitis - This condition causes the rheumatoid arthritis patient’s blood vessels to be inflamed. It can affect blood vessels on the skin, nerves, eyes, heart, finger, and toes. Symptoms of rheumatoid vasculitis include skin sores or ulcers, purplish bruises, pain and gangrene in fingers and toes, loss of feeling or tingling and pain in certain parts of the body, eye pain or redness, blurry vision, chest pain, and abnormal heart rhythms.
• Neurologic disease - Neurological manifestations of rheumatoid arthritis include entrapment neuropathies (carpal tunnel syndrome, tarsal tunnel syndrome), sensory peripheral neuropathy in the lower extremities, and cervical myelopathy.

How is rheumatoid arthritis diagnosed?

Early diagnosis means that patients can begin treatment as soon as possible. This helps to slow and even stop the disease from progressing and thus, reduce damage to the joints. Rheumatoid arthritis is diagnosed via:

• Blood tests
• Joint and organ examination
• X-ray
• Ultrasound

What are the treatment options for rheumatoid arthritis?

Medication and self-management strategies can help treat and manage rheumatoid arthritis. Rheumatoid arthritis medications like disease-modifying antirheumatic drugs and biological response modifiers (biologics) slow the disease. Corticosteroids (prednisone and cortisone) are used to help with pain and inflammation.

Self-management strategies can also help rheumatoid arthritis patients to be in control of their condition. This includes being active and exercising safely, maintaining a healthy weight, protecting joints and avoiding joint injuries, and seeing your doctor to control and manage the disease.

Book an appointment at Pantai Hospitals

If you or your loved one are experiencing joint pain or any of the other above-mentioned symptoms, do see a doctor immediately as early medical intervention can prevent further complications. The team of Rheumatology specialists at Pantai Hospital is able to provide accurate diagnoses and personalised treatment plans if there is indeed a medical issue.

References

1. American College of Rheumatology (Dec 2021) Rheumatoid Arthritis, Available at https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis [Accessed 22 Feb 2022]
2. Centers for Disease Control and Prevention (27 July 2020) Rheumatoid Arthritis (RA) Available at https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#:~:text=Rheumatoid%20arthritis%2C%20or%20RA%2C%20is,usually%20many%20joints%20at% [Accessed 22 Feb 2022]
3. Centers for Disease Control and Prevention (26 August 2021) Key Public Health Messages, Available at https://www.cdc.gov/arthritis/about/key-messages.htm [Accessed 22 Feb 2022]
4. Healthline (23 Nov 2021) Everything you want to know about rheumatoid arthritis, Available at https://www.healthline.com/health/rheumatoid-arthritis [Accessed 22 Feb 2022]
5. John Hopkins Arthritis Center (2022) Rheumatoid Arthritis Signs and Symptoms, Available at https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-symptoms/ [Accessed 22 Feb 2022]
6. John Hopkins Sjogren’s Center (2022) Symptoms of Sjogren’s Syndrome, Available at https://www.hopkinssjogrens.org/disease-information/sjogrens-syndrome/ [Accessed 22 Feb 2022]
7. Kevin D. Deane, M. Kristen Demoruelle. Lindsay B. Kelmenson, Kristine A. Kuhn, Jill M. Norris, V. MichaelHolersa (Feb 2017) Genetic and environmental risk factors for rheumatoid arthritis, Available at https://www.sciencedirect.com/science/article/abs/pii/S152169421730013X?casa_token=zePJm0ldcrUAAAAA:AsItXP0sLxhSLZE9UG-ZsgD28QH2z4x_xBLzNVa-eqBqHCF8O5bcUQm257J9HPpYRD_iDI8uSg [Accessed 22 Feb 2022]
8. Mayo Clinic (18 May 2021) Available at https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648 [Accessed 22 Feb 2022]