Joints
Noninfective arthritis
Rheumatoid arthritis

Author: Vijay Shankar, M.D. (see Authors page)

Revised: 30 August 2017, last major update May 2013

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: [Title] Rheumatoid arthritis

Cite this page: Shankar, V. Rheumatoid arthritis. PathologyOutlines.com website. http://pathologyoutlines.com/topic/jointsra.html. Accessed November 20th, 2017.
Definition / general
  • Chronic systemic inflammatory disorder affecting synovial lining of joints, bursae and tendon sheaths; also skin, blood vessels, heart, lungs, muscles (Davidson College: Rheumatoid Arthritis)
  • Produces nonsuppurative proliferative synovitis, may progress to destruction of articular cartilage and joint ankylosis
Epidemiology
  • 1% of adults, 75% are women, peaks at ages 10 - 29 years; also menopausal women
Sites
  • Small bones of hand affected first (MCP, PIP joints of hands and feet), then wrist, elbow, knee
Pathophysiology
  • Triggered by exposure of immunogenetically susceptible host to arthitogenic microbial antigen; autoimmune reaction then occurs with T helper activation and release of inflammatory mediators and cytokines that destroys joints; circulating immune complexes deposit in cartilage, activate complement, cause cartilage damage
  • Parvovirus B19 may be important in pathogenesis (Mod Pathol 2003;16:811)
Diagrams / tables

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Pathogenesis

Clinical features
  • Clinical course: variable; malaise, fatigue, musculoskeletal pain, then joint involvement; joints are warm, swollen, painful, stiff in morning; 10% have acute onset of severe symptoms but usually joint involvement occurs over months to years; most damage occurs in first 5 years, joints are unstable with minimal range of motion; 50% have spinal involvement
  • Reduces life expectancy by 3 - 7 years, death due to amyloidosis, vasculitis, GI bleeds from NSAIDs, infections from steroids
Diagnosis
  • Morning stiffness, arthritis in 3+ joint areas, arthritis in hand joints, symmetric arthritis, rheumatoid nodules, rheumatoid factor, typical radiographic changes
Laboratory
  • 80% have IgM autoantibodies to Fc portion of IgG (rheumatoid factor), which is not sensitive or specific; synovial fluid has increased neutrophils (particularly in acute stage), increased protein, low mucin
  • Other antibodies include antikeratin antibody (specific, not sensitive), antiperinuclear factor, anti rheumatoid arthritis associated nuclear antigen (RANA)
Radiology description
  • Xray: joint effusions, juxta-articular osteopenia, erosions and narrowing of joint space; destruction of tendons, ligaments and joint capsules produce radial deviation of wrist, ulnar deviation of digits, swan neck finger abnormalities
Radiology images

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Case of the Week #308:

Bony lesion

MRI of bony lesion

Case reports
Treatment
  • Nonsteroidal anti-inflammatory drugs (NSAIDs); immunosuppressive drugs; joint replacement (synovitis tends to lessen), synovectomy (inflamed synovium may recur and disease may continue to progress)
Clinical images

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Yellowish discharge of altered synovial fluid

Gross description
  • Joints have edematous, thick, hyperplastic synovium, covered by delicate and bulbous fronds
  • Osteophytes and new bone formation are not prominent
Microscopic (histologic) description
  • Dense perivascular inflammatory infiltrate of T lymphocytes, plasma cells (often with eosinophilic cytoplasmic inclusions called Russell bodies), macrophages; inflammation extends to subchondral bone (relatively specific for rheumatoid arthritis)
  • Proliferative synovitis with synovial cell hyperplasia and hypertrophy
  • Lymphoplasmacytic infiltrate with variable germinal centers, necrobiotic nodules and fibrosis
  • Increased vascularity with hemosiderin deposition
  • Organizing fibrin floating in joint space as rice bodies
  • Neutrophils present on synovial surface; osteoclasts present in bone forming cysts
  • Erosions, osteoporosis; pannus formation (synovium, synovial stroma with inflammatory cells, granulomatous tissue, fibroblasts), progressing to fibrous ankylosis (bridges joints), then ossifying to form bony ankylosis
  • Minimal evidence of repair (proliferative cartilage, sclerotic bone or osteophytes)
  • Weichselbaum's lacunae: enlarged chondrocyte lacunae within articular cartilage due to dead chondrocytes
  • Skin: rheumatoid nodules in 25%, usually those with severe disease in skin subject to pressure (ulnar forearm, elbows, occiput, lumbosacral area); also present in viscera; firm, nontender, with central fibrinoid necrosis surrounded by palisading epithelioid histiocytes, lymphocytes, plasma cells; obliterative endarteritis in vasa nervorum and digital arteries causes ulcers, neuropathy, gangrene
  • Blood vessels: small to medium size vessels in vital organs (not kidney) affected by severe erosive disease; rheumatoid nodules present, high titers of rheumatoid factor
Microscopic (histologic) images

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Amorphous, pink, necrotic material

Pannus

Rheumatoid nodule



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Case of the Week #308

Virtual slides

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Rheumatoid arthritis

Rheumatoid nodule

Cytology description
  • May have inflammatory exudate with neutrophils, suggesting an infectious arthritis
Molecular / cytogenetics description
Molecular / cytogenetics images

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HLA-DR4 molecule