Neuro Disorders: Rheumatoid Arthritis

Introduction

Rheumatoid Arthritis (RA) is an example of an autoimmune, inflammatory, systemic and rheumatological disorder.

Rheumatoid Arthritis is an;

Autoimmune disorder because - the immune system acts like a home dog that becomes rabid; starts attacking you instead of protecting.

Inflammatory disorder because - the process of inflammation dominates as to how it effectuates body damage. Inflammation is the normal physiologic process that takes place in the body (it is part of your immune system) and helps in defending the body along with tasks like repairing & healing the damaged tissues and organs. Although inflammation is normal, but if it happens unnecessarily it is then abnormal and causes more damage to the body than any help.

Systemic disease because - it can affect varieties of organs & tissues throughout the body.

Rheumatological disorder because joints are almost always involved but as mentioned above RA is more than just a joint disease.

Who gets this disease?

Generally it presents around the middle age say around 30 and 50. It can affect any race, ethnicity and both genders. The typical RA is not that frequent in extremes of age like children and old people. A variant called as Still’s disease occurs in children (but it is controversial whether it is a variant or not).

How does RA develop?

As mentioned above RA is an autoimmune disease condition, so dysfunctional immune system is what triggers the body damage. But it is not totally clear as to what exactly triggers this disruptive behavior of the immune system.

At this moment there are indications that both genetic and environmental issues play a role in the triggering of this disease. Presence of certain HLA genetic markers increase the susceptibility to develop RA and they include;

• HLA DRB1
• HLA DR4
• HLA DR1 etc.

It is thought that the disease process begins with microvascular damage and infiltration with inflammatory cells like macrophages, lymphocytes, fibroblasts etc. These activated cells secrete certain chemical agents which further draw more such cells and also initiate damage to the tissues like synovial membrane, cartilage in the joints and other tissues.

How does a patient with RA present?

RA manifestations can be categorized under two headings;

• The joint related presentations and
• The systemic (non joint) related presentations

The joint related presentations are seen as;

Poly arthritis (multiple joints damage) that is also generally symmetrical is characteristic feature of this condition. Although the smaller hand and finger joints are commonly involved large joints like knees, shoulder, hips can also get involved. RA may also affect upper cervical spine (mostly the joint between the first and second cervical vertebra).

Lot of stiffness, pain and swelling is seen with the affected joints.

The Systemic manifestations of RA include;

• Fatigue, low-grade fever, sick feeling, decreased appetite, weight loss etc.
• Skin nodules
• Inflammation of blood vessels (vasculitis)
• Heart and pericardial damage
• Lung and pleural damage
• Osteoporosis (thinning of bone)
• Ocular (eye damage)
• Felty’s syndrome
• Development of tumors rarely like lymphoma etc.

The following neurological involvement may be seen;

• Neuropathy of multiple kinds (mono neuropathy, polyneuropathy, mono neuritis multiplex etc)

• Vasculitis causing strokes
• Spine involvement especially the c1 and c2 (atlanto axial joint dislocation)and its complications

Diagnosis

The diagnosis of RA is usually made as below;

• Blood tests including ESR, RA factor, anti-CCP, ANA, complete blood count etc
• Radiological studies like xray, CT, NRI and one scans
• Tests on synovial fluid
• Synovial tissue biopsy etc.

Treatment

RA cannot be cured as of now and so managed symptomatically and with supportive measures.

The following medications are generally used;

• Non steroidal anti-inflammatory drugs (NSAIDs)
• Steroids like prednisone
• Disease modifying anti rheumatic drugs (methotrexate)
• Drugs like infiximab, rituximab (biologic agents)
• Immunosuppressive drugs like azathioprine

If conservative above measures fail then surgical treatments like joint replacement is required.

A neurologist is frequently involved in the care of patients with Rheumatoid Arthritis when they have diseases of the nervous system.



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