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RA, not just the joints


How many times has someone said to you, "Why do you take all those drugs? Just tough it out." Or how often have you heard a newly diagnosed person say. "I am not taking all those pills, I can handle the pain." If pain were the only problem RA presented, many of us would not be taking any medication at all. But sadly, that's not the case.

Rheumatoid arthritis is much more than stiff, painful joints. It does not just cause joint deformity if left untreated. It is a systemic disease, meaning it can attack all body systems. The usual weapon is inflammation.

This is presented not to scare you, but to make you fully aware of the power of rheumatoid arthritis. Here is a brief review of some of the body systems that RA can affect.

The Skin

Rheumatoid nodules form under the skin of about 25% of people with RA. These nodules tend to form near the joints; especially those joints subject to pressure, the elbows and wrists are common targets. Nodules may be single or multiple and vary from a few millimeters to 2 or more centimeters in size. Typically they come and go and are more of an annoyance than a problem. However on occasion they do ulcerate and infection becomes a concern. Nodules can also form in internal organs and on muscles and tendons.

Fragility is another common skin problem in people with RA. The skin becomes "thin" and bruising and tearing occurs. This can be further aggravated by the use of steroids.

Vasculitis, inflammation of the blood vessels, can cause skin problems including rashes, lesions and pain. Vasculitis causes much of the organ involvement in RA; this is discussed with each system.

The Heart

Not even the heart is safe from the grasp of rheumatoid arthritis. Pericarditis, an inflammation of the heart lining, is the most frequent heart problem caused by RA. As many as 40%-50% of those with rheumatoid arthritis have some evidence of pericarditis noted on autopsy. However the actual number of people with pericarditis symptoms and clinical evidence is much smaller, probably around 2%. It usually occurs when arthritis is active and virtually only in those people who are seropostive.

An inflammation of the coronary arteries is shown in up to 20% of people with RA at autopsy, both heart block and myocardial infarction have been reported as fatal complications of this inflammation. Rheumatoid nodules can be present in any of the heart structures, and an inflammation of the heart muscle. The valves and other heart structures can also become inflamed.

The Lungs

Although RA targets females at a rate of 3 to 1 compared to males, males more often have some sort of lung involvement. Pleural effusion, an inflammation of the lining of the lung, is the most common lung problem in people with RA. Between 38% and 73% of people with RA have evidence of pleural effusion on autopsy. Although rheumatoid pleural effusions may not cause any symptoms, it is in many cases accompanied by chest pain, fever, or shortness of breath.

Another fairly common lung problem with rheumatoid arthritis is the formation of rheumatoid nodules in the lung. In one study, 77 people with RA were evaluated by high resolution CT scan of the chest, 17 of them were found to have some degree of nodules present in the lungs. Again, these can present without causing any symptoms.

Interstitial lung disease (ILD) is another common lung manifestation of RA. Abnormalities suggestive of ILD are reported in 22% to 40% of people with RA. Other lung problems presented with RA include: Caplan's Syndrome, fibrosing alveolitis, pneumonitis and obliterative bronchiolitis.

The Kidneys

A decrease in kidney function can occur with RA. This is usually caused by an inflammation of the blood vessels of the kidney. It is usually mild, severe renal failure is rare in patients even with extensive rheumatoid vasculitis.

The gastrointestinal tract

The drugs we take to treat RA usually cause problems with the GI tract, however the disease itself, in rare cases, does involve the GI tract. This occurs when the blood vessels of the GI tract become inflamed, this is considered a very serious condition and must be treated aggressively.

The Nervous system

Nerve involvement in RA is very common, usually caused by inflammation of the joints or other structures pressing on or entrapping nerves. Carpal tunnel syndrome is a good example, the swelling of various structures in the wrist entrap the median nerve causing pain, numbness and tingling. Electromyographic (EMG) studies suggest that up to two-thirds of RA patients have evidence of median nerve compression in early disease. The same thing can occur around other joints.

Rheumatoid vasculitis may cause a nerve condition with patchy loss of feeling in one or more extremities, often in association with wristdrop or footdrop.

The Muscles

Muscle weakness and wasting are prominent features of rheumatoid arthritis, causing as much functional disability as joint pain. The wasting occurs most often in connection with acutely inflamed joints, but weakness and muscle stiffness may be generalized.

The Bones

Osteopenia or loss of bone density occurs not just at the joints, but is widespread particularly in long-standing rheumatoid arthritis. This may relate to immobility, steroid usage, and postmenopausal status in women. Rheumatoid disease itself may contribute to it by stimulating osteoclast activity.

The Eye

Corneal and conjunctival manifestations are the most common ophthalmologic features of rheumatoid arthritis. Episcleritis is an inflammatory condition causing redness of the eye and mild pain. Scleritis is more painful and may result in visual impairment. Sjogren's Syndrome occurs frequently in those with RA, adding to the potential for eye problems. According to rheumatologist Barry Waters eye problems are fairly common, "20%-25% of my RA patients have had some sort of eye problems related to RA, however these are easily treated and rarely serious."

The Throat

The larynx contains a joint called the cricoarytenoid joint, just like any other joint, it can be attacked by rheumatoid arthritis. Inflammation of this joint may cause pain and hoarseness. In very severe cases this inflammation can constrict the airway making breathing difficult.

Non Specific manifestations of RA

Anemia may be the most common extra-articular disease manifestation of RA. The degree of anemia is usually related to disease activity and improves with successful therapy. Dr. Susan Hoch states that as many as 80% of her patients with active RA have some degree of anemia.

Other non-specific manifestations include lymph node enlargement, seen in up to 75% of people with RA. Felty's Syndrome, which involves an inflammation of spleen, can occur in those with long standing, severe RA. Malaise, a general flu like feeling, often occurs and may reflect systemic disease with inflammatory cytokine production. Low grade fevers and night sweats are also common features of RA.

Depression is very common, especially early in the disease. We'll discuss dealing with the depression, malaise, and fatigue which often occur with other types of arthritis, in another Featured Discussion.

As you can see, RA is so much more than achy joints. It is indeed a systemic disease with the potential to affect almost every part of the body it can even be fatal. "Deaths from RA are rare, but every rheumatologist has seen it happen," says Dr. Barry Waters. Early, aggressive treatment is our best weapon with which to fight our enemy, RA.

References:
THORACIC MANIFESTATIONS OF THE SYSTEMIC AUTOIMMUNE DISEASES, Clinics in Chest Medicine, Volume 19, Number 4, December 1998, Copyright 1998 W. B. Saunders Company
Koopman: Arthritis and Allied Conditions, 13th ed., Copyright 1997 Williams & Wilkins
Goldman: Cecil Textbook of Medicine, 21st Ed., Copyright 2000 W. B. Saunders Company