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LAB FINDINGS:
No tests are specific for diagnosis of RA. However, rheumatoid factors, which are auto antibodies reacting with the Fc portion of the IgG,  are found in more than 2/3 of adults with the disease. Widely utilized tests largely detect IgM RF.

The presence of RF is not specific for RA. RF is found in 5% of healthy persons. In addition a number of conditions besides RA are  associated with the presence of RF.

These includes,
• SLE
• Sgogrens syndrome
• c/c liver disease
• sarcoidosis
• interstitial pulmonary fibrosis
• infectious mononucleosis
• Hepatitis B
• Tuberculosis
• Leprosy
• Syphilis
• Sub acute bacterial endocarditis
• Visceral leishmaniasis
• Schistosomiasis
• Malaria
• In normal individuals after vaccination or transfusion
• Relatives of individuals with RA

The serological test for detecting RA→Rose waler test.
Rheumatoid factor is uniformly found in patients with nodules or vasculitis.
In summary a test for the presence of RF can be employed to confirm a  diagnosis in individuals with suggestive clinical presentations and if present in high titer, the patients are at risk for severe systemic disease.

A number of additional auto antibodies may be found in patients with RA, including antibodies to filagrin, citrulline, components of the spliceosome (RA-33) and an unknown antigen Sa. Some of these may be useful in diagnosis in that they may occur early in the disease before RF is present or may be associated with aggressive disease.

BLOOD:
• normochromic normocytic anemia
• WBC count usually normal, but mild leukocytes may be present
• Esonophilia, when present usually reflects severe systemic disease
• ESR increased –above100mm/hr
• Serum electrophoresis ↑

SYNOVIAL FLUID ASPIRATION:
Confirms the presence of inflammatory arthritis, although none of the findings are specific.
• Turbid fluid with reduced viscosity, increasd protein content, &a slightly ↓ or normal glucose concentration
• WBC count above 1500/mm3. Neutrophils predominates.
• Compliment levels low.
A synovial fluid WBC count >2000/microL with more than 75% polymorpho nuclear leucocytes is highly characteristic of inflammatory arthritis. Although not diagnostic of RA.

RADIOGRAPHIC EVALUATION:

The prime aim of radiography is to determine the extend of cartilage destruction & bone erosion produced by the disease, particularly when one is monitoring the impact of therapy with disease modifying drugs or surgical intervention.

• Grade ---l ______ periarticular osteoporosis.
• Grade ---ll ______ loss of articular cartilage.
• Grade ---lll ______ erosions
• Grade ---lV ______ subluxation &ankylosis

DIAGNOSIS
Clinical examination + lab investigation.
The mean delay from the disease onset to diagnosis is 9 months

Criteria for Diagnosis of RA
(American Rheumatic Association 1988 Revision)

• Morning stiffness (> 1 hour)*
• Arthritis of three or more joint areas*
• Arthritis of hand joints*
• Symmetrical arthritis*
• Rheumatoid nodule
• Serum rheumatoid factor
• Radiographic changes

* Duration of 6 weeks or more

Diagnosis made with 4 or more criteria

DIFFERENTIAL DIAGNOSIS.
1. Rheumatic arthritis
2. psoriatic arthritis
3. gout
4. osteoarthrosis
5. allergic arthritis
6. syphilitic arthritis
7. gonococcal arthritis
8. reiters syndrome
9. ankylosing spondilitis
10. allergy to TB(poncets syndrome)
11. serum sickness like reaction
12. reaction in leprosy
13. drug induced arthralgias
14. infections—brucellosis,boraliosis
15. joint TB
16. SLE
17. scleroderma
18. poly myositis
19. dermatomyositis
20. lyme disease

VARIENTS OF RA
1. Juvenile polyarthritis(including still’s disease)
2. felty’s syndrome
3. sjogrens syndrome
4. palindromic rheumatism.

MANAGEMENT
The goal of therapy is
• relief of pain
• reduction of inflammation
• protection of articular structures
• maintenance of function
• Control of systemic involvement.

General measures
During acute and sub acute phase
Rest splinting &various forms of heat applications.
When pain subsides exercise re started with a view to maintain normal range of movements in all joints and prevent swelling of muscles.
Educating the patient.

Physiotherapy
• To produce comfort, relieve pain &aid in recovery.
• To prevent deformities &loss of function of joints.
• To help in functional &corrective rehabilitation

Surgical correction to prevent deformities

Occupational therapy
• Life style modification
• Change of occupation

Social rehabilitation

Medicinal therapy
Includes
• Management of acute stages
• Selection of similimum
• Intercurrent remedies and
• Antimiasmatic medicine

For the selection of similimum the case has to be taken in detail and we should work out the case based on the symptoms selected from the case.
The following rubrics can be generally used for the repertorisation or as potential differential field.

From Synthesis
1. Extremities; stiffness; hands; rheumatic;
2. Extremities; stiffness; hands; morning;
3. Extremities; stiffness; fingers; morning;
4. Extremities; swelling; fingers; joints;
5. Extremities; arthritic nodosities;
6. Extremities; arthritic nodosities; finger joints;
7. Extremities; inflammation; joints; synovitis;
8. Extremities; pain; rheumatic;
9. Extremities; pain; rheumatic; acute;
10. Extremities; callosities; soles;
11. Extremities; Raynaud’s disease;
12. Eye; inflammation; uvea;
13. Eye; inflammation; sclera;
14. Eye; inflammation; rheumatic;
15. Eye; inflammation; cornea;
16. Eye; dryness;
17. Chest; inflammation; heart; endocardium; rheumatic;
18. Chest; inflammation; lungs;
19. Chest; edema; pulmonary;
20. Skin; indurations; nodules;
21. Generals; softening; bones;
22. Generals; weakness; muscular;
23. Generals; anemia;
24. Generals; swelling; glands;
25. Generals; tobacco; agg;

A CASE STUDY

CASE RECORD  OP. NO:16004   SERIAL NO:          DATE: 25/06/2001

PATIENT PARTICULARS:
NAME: Mrs: XXX
AGE:63
SEX: Female
ADDRESS: XXX
MARITAL STATUS: Married
RELIGION:Christian
OCCUPATION: House wife
(Case submitted by Dr: Sinsen Joseph)


PRESENTING COMPLAINTS:
Pain in both left upper and lower limbs since 20 years.
< waking, early morning,wet weather
Swelling with stitching type of pain in left wrist joint since > 6 months
Stiffness of inter phalangeal joints of hands with difficulty in using the arms in the morning

HISTORY OF PRESENTING COMPLAINTS:
The complaint started as pain in soles of both feet 20years back. The complained was aggrevated by walking , during winter season.Now there is pain in left upper and lower limbs.

PAST HISTORY: -
No particular complaints in the past history.

FAMILY HISTORY:-
H/o Diabetes in the family. Mother is having rheumatic complaints and she is diabetic. Father died by drowning. Two brothers of the patient is having valvular disease of heart.

TREATMENT HISTORY:-
Took allopathic and ayurvedic treatments with slight relief .

PERSONAL HISTORY:-
B/b at Kothamangalam. Now the patient is living at Perambra. Married and having 5 children. House wife. No undesirable habits.

REGIONALS:
Head: Occational headache
Eye: Pain in left eye.
Stomach: Appetite is normal.
Thirst is normal and prefers warm drinks(habit).
No particular desires and aversions.
Rectum: Regular.
Urine: No complaints.
Sweat:Moderate.
Sleep: Decreased. 9pm to 4am. Lies on the back. Now prefers covering.
Menstrual history: Profuse bleeding .H/o dysmenorrhoea. Regular menses.
Fever: There is pain with chilliness
Mental General: She is a mild and gentle lady. Her complaints are relieved by weeping.There is general relief from Consolation.

PHYSICAL EXAMINATION:
A. GENERAL: Moderately built and nourished.
There is no conjunctival pallor, no cyanosis, no clubbing , not icteric , no generalized lymphadenopathy.
BP:126/78mm of Hg. PULSE RATE:68/mint. RESP.RATE:14/min. TEMP:98.8F

B. EXAMINATION OF LOCOMOTOR SYSTEM: The joints are tender and warm . No crepitus .. NO Scoliosis.No joint deformity.

C. EXAMINATION OF OTHER SYSTEMS.
Examination of respiratory system: NAD
Examination of CNS : NAD
Examination of CVS : NAD

PROVISIONAL DIAGNOSIS WITH D / D: ? Rheumatiod Arthritis.
D/d : 1. a/c rheumatic fever
2. poly arthritis.

INVESTIGATIONS: On 8/7/2001
Blood; TC 7500cells/cmm
P68 L28 E4
ESR 56mm/hr
Hb 11.2 gm%
RBS 108mg%
Serum: Rheumatoid Factor +ve
X-ray Hand joints : NAD

FINAL DIAGNOSIS: RHEUMATOID ARTHRITIS

ANALYSIS AND EVALUATION OF THE CASE:
Mental Generals: Consolation amelioration
Weeping .
Physical General:Sleeping on the back.Pain with chilliness.
Particulars: Pain in joints <walking, early morning, wet weather.
Headache.Pain in eyes.

REPERTORISATION;
Rubrics selected;
Mind; Consolation; amel;
Sleep; Position; back on ;
Fever; Chilliness with ;
Stomach;Desire; warm drinks;
Extremeties ; Pain;Morning ;waking on;
Extremeties ; Pain; rheumatic;
Extremeties ; Pain; wet weather;

Repertorial result; Puls 16/6; Bry 10/4; Calc 10/4

MANAGEMENT OF THE CASE:
GENERAL: Rest for 2 weeks. Avoid exposure to cold.
MEDICINAL: Pulsatilla.
BASIS OF SECLECTION:Reportorial prescription based on Kent repertory.
The patient is mild in character, consolation >,weeping.Prefers to lie on back. There is pain with chilliness.These points to Pulstilla.

OBSERVATION AND FOLLOW UP:
Date                   Symptoms                                                      Medicine

25/06/2001 Pain in joints,stiffness,chilliness of body.                 Pulsatilla IM/1d BT for 1month

01/07/2001 General relief
Occassional headache
Occassional joint pains Pulsatilla IM/1d
BT for 1month

06/08/2001 Pain in soles Pulsatilla IM/1d
BT for 1month

21/09/2001 Pain in joints slight >
occasional stiffness
Blood: ESR 53mm/hr
Hb 10.2gm%
TC 6400cells/cmm Pulsatilla IM/1d
P66 L34 BT for 1month
Serum: RA factor: NEGATIVE

01/06/2002 Pain in joints slight<
Hb: 11.8 gm%, ESR: 05mm/hr. Pusatilla IM/1d
BT for 1 month

INFERENCE OF THE CASE: The patient is steadly improving under Pulsatilla.The treatment is continuing.

References:
1. Harrison’s Principles of internal medicine
2. Davidson’s text book of medicine
3. Text book of medicine by Dr:K.V.Krishnadas
4. Cessil’s text book of medicine
5. Oxford text book of medicine
6. Synthesis by Friederick Schroyens.
7. Articles published in the internet by American Rheumatic Association.

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