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
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
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.
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.
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
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
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
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.
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.
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
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.
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 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.
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.