Thank you to Dr. George for his expert insight in our discussion of a complicated case of rheumatoid arthritis. The patient presented post-partum with fairly symmetric inflammatory polyarthralgias and pleuritic pain.

We discussed a differential diagnosis combining these two primary presenting features of this patient’s clinical course, which included the following:

ra1The patient’s workup was notable for positive rheumatoid factor and CCP, which were supportive along with the clinical presentation of a diagnosis of rheumatoid arthritis. In patients with inflammatory arthritis, if they present with an accessible effusion it may be a good idea to perform arthrocentesis to ensure there is no concomitant crystal disease or infection. Some rheumatologists will also get baseline imaging.

The pathogenesis of rheumatoid arthritis is thought to be related to possibly underlying genetic susceptibility and environmental exposures that cause loss of self-tolerance in the host, and development of rheumatoid factor which can then incite inflammation and tissue damage. This is illustrated in the figure below from NEJM (full reference below).RA2Rheumatoid arthritis can be difficult to treat, and it can have systemic manifestations in addition to joint involvement. All patients with RA should be treated with DMARDs early in their course, with the goal of intervening to prevent irreversible damage. Methotrexate is commonly used. Anti-inflammatory medications and steroids can be used as adjunct therapy during times of high disease activity, but do not replace the role of DMARDs and should not be used alone! Several other medications have been studied in varying combinations; patient demographic factors must also be considered, particularly in females of child-bearing potential. Finally, all patients with this diagnosis should be referred to a rheumatologist!

McInnes IB, Schett G. The Pathogenesis of Rheumatoid Arthritis. N Engl J Med 2011; 365:2205-2219December 8, 2011DOI: 10.1056/NEJMra1004965.