Make your own free website on Tripod.com

Inflammatory Arthritis - RA

Lupus - RA

Home | Immune System - Notes | Surgery | Disease Process RA | Arava | Case I RA | Case II RA | Overview RA | Anakinra | Enbrel | Remicade | Humira | Corticosteroid | Toxicity RA | Treatment RA | Therapy I - RA | Therapy II | Monitoring - RA | Diagnosis - RA | Tests | Arthritis-RA | Strategies - RA | Drugs I - RA | Drugs II | Biologics | Onset RA | My Personal Battle-RA | Inflammatory | Lupus - RA | Rheumatic Diseases | Osteoporosis | Flares | R A | Medication - RA | Summary | Steriods -RA | Research RA | Updates RA | Management RA

dolphin-01.gif

SLE;  Is the most serious of the lupus group of diseases;
Systemic lupus erythematosus:
 
Patients with SLE (female:male ratio is about 10:1) frequently present with polyarthritis - typically a peripheral polyarthritis with symmetric involvement of both small and large joints. The physician should question the patient in detail about symptoms that reflect multisystem involvement, particularly photosensitivity, unexplained rashes, malar rash, pleuritic chest pain, history of seizures, oral ulcers, hair loss, Raynaud's phenomenon, fevers and sweats.
 
Deformities including subluxation at the MCP joints, ulnar deviation, "swan neck" and boutonniere deformities (Jaccoud's arthropathy) may develop in about approximately 15% of patients with SLE, but these are not associated with joint erosion. (*polyarthritis--inflammation in more than 4 joints).

If, on the base of history and the physical examination SLE is suspected the physician should order an antinuclear antibody test;this is a useful screening test because a negative test result will virtually exclude SLE. If the test is positive and there is clinical suspicion of multisystem disease, the physician should consider further serologic tests and refer the patient to a rheumatologist.

For SLE patients without serious internal organ involvement hydroxychloroquine is the drug of choice because it has been shown to improve disease control, prevent flares and improve long-term outcomes. Arthritis and pleurisy respond to NSAIDs. Steroid medications may also be required in low and moderate doses either intermittently or continuously.

Immunosuppressant drugs are required for those with serious internal organ involvement (e.g., cerebritis or glomerulonephritis).

SLE can fluctuate between active period (flare ups and exacerbation),and minimal symptoms or no symptoms (remission). Other types of lupus are discoid lupus erythematosus (DLE) and subucutaneous lupus (SCLE). With these types of lupus, skin rashes and sun sensitivity are the main symptoms,and the internal organs are not attacked. Approximately 10 % of people diagnosed with these limited forms of lupus go on to develop SLE.

Pain in the muscles and joints of the hands, arms, shoulders, feet, knees, hips or jaw. The pain may move from area to area and may cause the skin to feel hot, be red or swell. Fever and loss of appetite.Sudden and unexplained weight loss or gain.

Sometimes the rash is across the cheeks and bridge of the nose. This is called butterfly rash. Sometimes the rash is red,and scaly,and appears on the face,scalp,ears,arms,or chest. A milder form of lupus called discoid lupus  (DLE) causes this type of rash.

Small usually painless sores in the moist lining of the mouth or nose may appear. These are called mucosal ulcers. Changes in colour of the fingers when they are exposed to cold may be seen in some patients.

Sensivity to sunlight-increase in the number and severity of headaches-increase in loss of hair over the scalp-ongoing high blood pressure-swelling of feet and legs-chest pain when lying down,or taking deep breaths are symptoms seen in some patients.

SLE is a different disease for each person. Each patient has their own combination of symptoms as the disease targets the body's tissues and these symptoms range from mild to severe. If one experiences three or more of the warning signs,see a physician..

Some people with SLE may require no treatment if their symptoms are not severe and their disease is mild Treatment plans are based on the type and severity of symptoms which are individualized to meet each person's needs. No one test can diagnose lupus.

Although "lupus" is used as a broad term, there actually are several kinds of lupus:

  • Systemic lupus erythematosus (SLE) is the form of the disease that most people are referring to when they say "lupus." The word "systemic" means the disease can affect many parts of the body. The symptoms of SLE may be mild or serious. Although SLE usually first affects people between the ages of 15 and 45 years, it can occur in childhood or later in life as well. This booklet focuses on SLE.
  • Discoid lupus erythematosus refers to a skin disorder in which a red, raised rash appears on the face, scalp, or elsewhere. The raised areas may become thick and scaly and may cause scarring. The rash may last for days or years and may recur. A small percentage of people with discoid lupus have or develop SLE.
  • Drug-induced lupus refers to a form of lupus caused by specific medications. Symptoms are similar to those of SLE (arthritis, rash, fever, and chest pain) that typically go away when the drug is stopped.
  • Neonatal lupus is a rare form of lupus affecting newborn babies of women with SLE or certain other immune system disorders. At birth, the babies have a skin rash, liver abnormalities, or low blood counts, which entirely go away over several months. However, babies with neonatal lupus may have a serious heart defect. Physicians can now identify most at-risk mothers, allowing for prompt treatment of the infant at or before birth. Neonatal lupus is very rare, and most infants of mothers with SLE are entirely healthy.

Crossover,or overlap syndrome indicates features that overlap into another rheumatic disease. e.g., Rhupus (coined phrase) -overlap of RA and lupus.

Arthritis: This is one of the most common features in lupus. It occurs in the same pattern as rheumatoid arthrits-involving many joints,small and large,on both sides of the body,and particular the knucles of the fingers.

There is a couple of big differences from RA,however. The arthritis tends to be milder.reponds to treatment more easily and  does not  result in cartilage and bone damage. While the intense inflammation in the fingers may cause finger deformity, this is uncommon (less than 10 %). When it does happen,it's because of inflammatory weakening of the ligaments supporting the joints.

Joint pains (arthralgia) without obvious inflammation are as common as swollen joints. The tendons that anchors the kneecap to the upper shinbone may become weakened and even rupture.

Inflammation in the covering (the pleura) of the lungs (pleurisy),and inflammation of the lining of the heart (pericardium) is called pericarditis. The inflammation itself is usually without symptoms. When symptoms do occur,though,they can be very serious.

Like just about every other part of the body,if the kidneys are carefully studied in patients with lupus,some abnormality will usually be found. And as with just about every part of the body,these abnormalities can be very serious,but usually aren't.

Almost every part of the nervous system can be affected by lupus inflammation, when it occurs. The two most common problems,are headache, usually of  the migrane type,  and difficulties with ,memory,learning,and concentration. 

A number of other effects are not common,but do occur. These include coma, stroke seizures, and nerve damage. Psychiatric symptoms,in particular severe depression,may dominate in certain patients.

Sorting out these problems,trying to determine if they are caused by lupus itself,by the treatment of lupus,or some other factor,can be difficult.

If the patient has only a few symptoms-such as joint pain-and the ANA test is positive, a diagnosis of lupus is hard to make. Some patients need to be followed and tested for years before the picture becomes crystal-clear.

If the lupus is active,adequate rest is important-even to the point of taking time off from regular activities.

The Latin meaning for Lupus is "wolf" perhaps,because of it' many different symptoms. Some refer Lupus as a disease with "1000 faces". Lupus can be a life-threatening disease. RA also has mild,moderate,and severe types of cases.

Lupus strikes about one in two thousand people-fourteen to fifteen thousand Canadians -women eight to ten times more often than men. It usually appears in women between the ages of twenty and forty,although it can occur at any age in either gender and is equally common to both after age fifty. In severe cases it may cause death. In fact,as recently as the 1940s,only one patient in six survived three years after diagnosis.

Thanks to extensive clinical and basic science research,that last grim syatistic has been radically upgraded,to something like one fatality in ten cases a decade after diagnosis. by far,the majority of people with lupus live full,basically normal lives,as the disease and it's symptoms can usually be treated,as in RA.

People with lupus often suffer from a double affliction. There's the disease itself,but added to that is an emotionally corroding experience: the misunderstanding and skepticism,sometimes outright disbelief,that many people with lupus are subjected to by colleagues,family members,and friends-even some physicians. It's partly a visibility problem: How can you be sick,someone will ask,when you look perfectly healthy ? I am sure many RA patients have sililar experiences.

Such queries usually reflect the disease's own fickle mercies. Sometimes you're up,sometimes down,victim to a inconstant spectrum of ills. Lupus isn't a "true" form of arthritis;more accurately,it's a connective-tissue disease,though it's classified as a rheumatic disease because it's symptoms usually include joint pain and swelling. About half of all people with lupus do develop recognizable arthritis,though very few of them suffer the deformities associated with that disease.

There are still major questions concerning the cause,or causes,of lupus,and a cure is still,far off. (It's known that some people develop drug-induced lupus from taking medications for other conditions.) It is certain,that lupus is an autoimmune disease,a disorder in which the body's own defenses turn on itself.

Furthermore,there appears to be an inherited predisposition for the disease,although the specific gene or genes involved have yet to be clearly defined. Current theory suggests that heredity alone can't explain why some people develop the disease while others don't. Some external trigger,perhaps a bacterium or virus,may be resposible for starting the disease process in genetically predisposed people. It could also be the result of one or more environmental factors,such as childbirth,hormonal changes,a traumatic injury,an infection-even sunlight-we still don't know for sure.

In some people with lupus, only one system of the body such as the skin or joints is affected. Other people experience symptoms in many parts of their body. Just how seriously a body system is affected also varies from person to person. Most commonly, joints and muscles are affected, causing arthritis and muscle pain. Skin rashes are quite common. The following systems in the body also can be affected by lupus.

  • Kidneys: Inflammation of the kidneys (nephritis) can impair their ability to get rid of waste products and other toxins from the body effectively. Because the kidneys are so important to overall health, lupus affecting the kidneys generally requires intensive drug treatment to prevent permanent damage. There is usually no pain associated with kidney involvement, although some patients may notice that their ankles swell. Most often the only indication of kidney disease is an abnormal urine or blood test.
  • Lungs: Some people with lupus develop pleuritis, an inflammation of the lining of the chest cavity that causes chest pain, particularly with breathing. Patients with lupus also may get pneumonia.
  • Central nervous system: In some patients, lupus affects the brain or central nervous system. This can cause headaches, dizziness, memory disturbances, vision problems, stroke, or changes in behavior.
  • Blood vessels: Blood vessels may become inflamed (vasculitis), affecting the way blood circulates through the body. The inflammation may be mild and may not require treatment or may be severe and require immediate attention.
  • Blood: People with lupus may develop anemia, leukopenia (a decreased number of white blood cells), or a decrease in the number of platelets (thrombocytopenia). Some people with lupus may have abnormalities that cause an increased risk for blood clots.
  • Heart: In some people with lupus, inflammation can occur in the heart itself (myocarditis and endocarditis) or the membrane that surrounds it (pericarditis), causing chest pains or other symptoms. Lupus can also increase the risk of atherosclerosis.

Diagnosing lupus can be difficult. It may take months or even years for doctors to piece together the symptoms to diagnose this complex disease accurately. Making a correct diagnosis of lupus requires knowledge and awareness on the part of the doctor and good communication on the part of the patient. Giving the doctor a complete, accurate medical history (for example, what health problems you have had and for how long) is critical to the process of diagnosis. This information, along with a physical examination and the results of laboratory tests, helps the doctor consider other diseases that may mimic lupus, or determine if the patient truly has the disease. Reaching a diagnosis may take time and occur gradually as new symptoms appear.

No single test can determine whether a person has lupus, but several laboratory tests may help the doctor to make a diagnosis. The most useful tests identify certain autoantibodies often present in the blood of people with lupus. For example, the antinuclear antibody (ANA) test is commonly used to look for autoantibodies that react against components of the nucleus, or "command center," of the patients own cells. Most people with lupus test positive for ANA; however, there are a number of other causes of a positive ANA besides lupus, including infections, other rheumatic or immune diseases, and occasionally as a finding in normal healthy adults. The ANA test simply provides another clue for the doctor to consider in making a diagnosis. In addition, there are blood tests for individual types of autoantibodies that are more specific to people with lupus, although not all people with lupus test positive for these and not all people with these antibodies have lupus. These antibodies include anti-DNA, anti-Sm, anti-RNP, anti-Ro (SSA), and anti-La (SSB). The doctor may use these antibody tests to help make a diagnosis of lupus.

Some tests are used less frequently but may be helpful if the cause of a persons symptoms remains unclear. The doctor may order a biopsy of the skin or kidneys if those body systems are affected. Some doctors may order a syphilis test or a test for anticardiolipin antibody. A positive test does not mean that a patient has syphilis; however, the presence of this antibody may increase the risk of blood clotting and can increase the risk of miscarriages in pregnant women with lupus. Again, all these tests merely serve as tools to give the doctor clues and information in making a diagnosis. The doctor will look at the entire picture--medical history, symptoms, and test results--to determine if a person has lupus.

Other laboratory tests are used to monitor the progress of the disease once it has been diagnosed. A complete blood count, urinalysis, blood chemistries, and erythrocyte sedimentation rate (ESR) test can provide valuable information. Another common test measures the blood level of a group of substances called complement. People with lupus often have increased ESRs and low complement levels, especially during flares of the disease.

Systemic lupus erythematosus (also called SLE or lupus) causes a variety of problems. It may cause skin rashes, arthritis, anemia, seizures or psychiatric illness, and often affects internal organs including the kidneys, lungs and heart. Once a disease with high mortality, SLE is now considered a chronic disease. In 1954, survival after 4 years was 50%; today it is more than 97%.

SLE is a chronic inflammatory disorder resulting from an abnormality of the immune system, which normally functions to protect the body against cancers and invading infections. In SLE, the immune system is over-active and produces too many abnormal antibodies that react with the patients own tissues. The exact cause of lupus is not known, but heredity, environment and hormonal changes may be involved.

 Health Impact:

  • Prevalence of SLE is 40 to 50 per 100,000.
  • It is more common in certain ethnic groups, particularly among blacks.
  • More than 85 percent of lupus patients are women.

Summary:  Because of its wide variety of symptoms,diagnosis is often difficult it requires a high degree of awareness and experience among physicians. Typical features of SLE include: 

  • A butterfly-shaped rash over the cheeks
  • A skin rash appearing in areas exposed to the sun
  • Sores in the mouth and nose
  • Arthritis involving one or more joints
  • Kidney inflammation
  • Nervous system disorders including seizures, mental disorders and strokes

Fever, weight loss, hair loss, poor circulation in the fingers and toes, chest pain when taking deep breaths (pleurisy) and abdominal pain are often seen. Laboratory studies are crucial to diagnosing SLE. In particular, the antinuclear antibody (ANA) test is almost always positive in SLE. A precise diagnosis is often appropriately delayed because the disease may evolve gradually.

Treatment for SLE depends on the clinical problems present and whether the disease is active or not at a given time. Earlier and more accurate diagnosis, better understanding of the immune abnormalities in SLE, and treatment studies have all contributed to improved treatment of patients with SLE.

Regular medical evaluation is important to monitor SLE. Drug treatment must be individualized for each patient, depending on the particular problems and their severity. For mild inflammation, nonsterodial anti-inflammatory medications are helpful. Corticosteroids, the single most important drugs to treat SLE, must be used judiciously. Bone protection is important when steroids are used. Anti-malarials such as hydroxychloroquine reduce SLE activity and are helpful for the skin and joints. More severe SLE requires immunosuppressive drugs such as azathioprine and cyclophosphamide. The disease often enters quiet periods with little or no activity (remission), during which medications can be reduced and occasionally discontinued

That unknown trigger is just part of the reason physicians are at such pains to diagnose the condition. then there's the fact that no two patient's suffer,or present with symptoms,in quite the same way. Symptoms can include any thing from hair and weight loss and rashes to ulcerated mouth sores and throat and facial swelling (which may indicate kidney failure). Some people develop mainly joint problems. And any patient can get any combination of the full menu.

Diagnosis begins with a patient's history. A family history of lupus or another immune disorder,such as RA,is a strong clue. The physician then performs a physical examination to confirm suspecions raised by the history. Joint inflammation,for example,would suggest arthritis,but if there's a rash that flares from exposure to the sun,or other rashes on the body consistent with lupus the diagnosis is clearer.

There are a number of other techniques a physician can perform to confirm the diagnosis,including tests for inflammation around the lungs and heart. There are also lab tests to identify lupus-associated immunological dysfunctions,including tests for FANA (fluorescent antinuclear antibody),anti-DNA,and anti-Sm (a substance found in cell nucleii that was named after a patient-named Smith- in whom the first "anti-Smith" antibody was found).

MCTD And UCTD:
 
RA will drastically change your life. We do not think about about our health unless it is threatened. To live a normal life joints must function perfectly .Even minor joint disease causes many changes.Diseases such as RA which affects the whole sytem,may limit quality of life. Quality of life is a medical term used as a measure of how one functions and enjoy life. The term includes a sense of happiness and sense of well-being. A sense of well-being involves one's ability to interact with your partner and your family,to do your job,and your children.
 
The extra-articular features of RA can also have on impact on quality of life. Tendonitis causes difficulty when you try to move your joints. If the internal organs become involved this can lead to a loss of function (e.g., if the lungs become involved in the inflammatory process,shortness of breath or loss of exercise tolerance can occur).
 
When one feels ill,nauseous and tired it is difficult to be cheerful let alone accomplish what you want to do. Interactions with family and friends,even performing your job,can become difficult.
 
Rheumatic Disease--Notes:
Connective tissue diseases are a special group of rheumatic diseases (diseases that features abnormalities of the muscle and/or joints} that can be associated with arthritis. They are characterized as a group by the presence of spontaneous over-activity of the body's immune system. This over-activity results in the production of unusual antibodies that are found in the blood. The antibodies may or may not cause any problems by themselves in patients with connective tissue diseases but they are commonly found in the blood as a characteristic feature.
 
The connective tissues are the structural portions of our body that essentially hold the cells of the body together. These tissues form a framework or matrix. for the body. the connective tissues are composed of two major structural protein molecules,collagen and elastin there are many different types of collagen  protein molecules,collagen and elastin they also vary in amount in each of the body's tissue.In patients with connective tissue disease,it is common  for collagen and elastin to become injured due to inflammation. Elastin is the major component of ligaments,
 
Mixed connective tissue disease (separate from extra-articular features of RA) was first described in the early 1970s' is "classically "considered as a "overlap" or mix,of three specific connective tissue disease,SLE,scleroderma.and polymyositis. Patients with this pattern of disease (MCTD) have features of each of these 3 diseases. They also typically have very high quantities of ANAs antinuclear antibodies and antibodies to ribonucleoprotein (anti-RNP) detectable in their blood.
 
The symptoms of many of these patients eventually evolve to become dominated by features on one of the 3 component illness most commonly the scleroderma features.
 
It is now known,however,that overlap syndromes can involve any combination of the connective tissue diseases. Therefore, e.g., patients can have a combination  of RA and SLE (hence,the coined name "rhupus").
 
Accordingly,today,true mixed connective disease is diagnosed when patients demonstrate the clinical features (exam findings) of overlap illness. These patients also have high amounts of ANA and anti-RNP without having such other antibodies as the dsDNA,antibodies of SLE and SC 170 antibodies of scleroderma--systemic lupus erythematosus.
 
When these conditions have not developed the classic features of a particular disease,doctor will refer to the condition as "undifferentiated connective disease or "UCTD". this designation implies that the characteristic features that are used to define the classic connective tissue diseases are not present,but that some symptoms or signs of a connective tissue disease exist-e.g., a person may have a special antibody in the blood such as  ANAs and muscle pains,but no other definite features of a classic connective tissue disease. Individuals with UCTD may never develop a fully definable condition or they may eventually develop classic tissue disease.

Vasculitis:

The actual cause of the vasculitis diseases is usually not known. However, immune system abnormality and inflammation of blood vessels are common features. Each form of vasculitis has its own characteristic pattern of symptoms. Examples of vasculitis include Kawasaki disease, Behcet's disease, polyarteritis nodosa, Wegener's Granulomatosis, Takayasu’s Arteritis, Churg-Strauss Syndrome, giant cell arteritis (temporal arteritis), and Henoch Schonlein Purpura.

Vasculitis can also accompany infections (such as hepatitis B), exposure to chemicals (such as amphetamines and cocaine), cancers (such as lymphomas and multiple myeloma), and rheumatic diseases (such as rheumatoid arthritis, systemic lupus erythematosus).

Laboratory testing of blood or body fluids in a patient with active vasculitis generally indicates inflammation in the body. Depending on the degree of organ involvement, a variety of organ function tests can be abnormal.

The diagnosis of vasculitis is ultimately established after a biopsy of involved tissue demonstrates the pattern of blood vessel inflammation. Examples of tissues used for biopsy include skin, sinuses, lung, nerve, and kidney. Depending upon the situation, an alternative to biopsy can be an x-ray test of the blood vessels called an angiogram.

The treatment of the various forms of vasculitis depends on the severity of the illness and the organs involved. Treatments are generally directed toward stopping the inflammation and suppressing the immune system. Typically, cortisone-related medications, such as prednisone, are used. Additionally, other immune suppression drugs, such as cyclophosphamide (Cytoxan) and others, are considered. Additionally, affected organs (such as the heart or lungs) may require specific medical treatment when the disease is active.

RA of the Spine:
 
As with any joint in the body, the small joints of the spine can be destroyed by rheumatoid arthritis. This can lead to instability, pain and in advanced cases to compression of the spinal cord and nerve roots emerging from it. This occurs most commonly in the upper neck, but may affect the lower neck or lower back as well.

One in five to one in three patients with RA have spinal. I was taught that at one time it was thought that spinal involvement was not involved in RA. It is untrue.

Aside from a physical examination,which includes assessment of the patient's neurologic functions,X-rays are obtained. These usually include neck x-rays,in which the patient is asked to bend their head forward then backward. Obviously,if the patient has symptoms in other areas of the spine,x-rays of other areas should be taken as well. If these areas show reason for concern an MRI scan will usually be ordered next. Sometimes a CAT scan (CT) or Bone scan may be added.

In early stages of RA, anti-inflammatory medications can be effective in decreasing pain and may slow the progression of joint destruction caused by RA.

Once joint destruction of the spine has set in, there are no specific exercises that can stop or arrest the development of spinal instability. Maintenance of a normal body posture and a low-impact exercise program are necessary to avoid severe secondary problems, such as spontaneous spine fractures and maintain reasonable levels of cardiopulmonary fitness.

Chiropractic manipulation of RA patients with spinal involvement is, however, clearly contraindicated due to the risk of causing spinal instability to worsen. Cases of paralysis after spine manipulation have been reported.

Spine surgery can improve the quality of life of an affected RA patient in several major ways:

  • By resecting a diseased joint and creating a permanent bond between the affected vertebrae (in a procedure referred to as "fusion"), rheumatoid arthritis and its related symptoms are extinguished from that area.
  • Restoration of a normal spinal alignment prevents deterioration of basic vital functions, such as cardiopulmonary fitness.
  • Stabilization and, if necessary, realignment of the spine can protect the patient’s spinal cord from potentially catastrophic injury.
  • Decompression of compromised nerves can decrease pain, halt progressive loss of nerve function and may even

 
EPISCLERITIS presents as a minor discomfort in one or both eyes. There may be a patch of redness on the white of the eye (sclera) near the cornea and iris. It does not affect the vision or cause diplopia (double vision). It is associated with vasculitis (inflammation of blood vessels) elsewhere as well as worse rheumatoid arthritis (RA), that is worse joint disease and more non-joint complications such as nodules. Episcleritis is transient but may recur. It usually needs no treatment but steroid eye drops may help. It is not uncommon in RA but can also occur with other conditions such as Wegener's granulomatosis and inflammatory bowel disease.
 
SCLERITIS affects the sclera of one or both eyes in RA but it is rare. It is due to a similar process as the rheumatoid nodule. It can be associated with eye pain, altered vision (but not diplopia), a patch of purple or blue discoloration of the white sclera and rarely perforation of the eyeball. It requires potent treatment of the RA with immunosuppressants etc.
 
CORNEAL MELT SYNDROME is a rare complication of RA in which the cornea is gradually destroyed. Vision is reduced or lost but there is no diplopia. It requires potent drugs like cyclosporin and sometimes cornea transplants.
 
RETINAL VASCULITIS is an inflammation of the blood vessels in the retina of the eye. It usually causes no symptoms other than blind spots sometimes.
 
SJOGREN'S SYNDROME causes dryness of the eyes (keratoconjunctivitis sicca--KCS).  It is the commonest eye problem due to RA. It is helped by artificial tears etc. Persistent dryness can lead to corneal ulcers and scarring.
 
BROWN'S SYNDROME is rare. It is an inflammation of the tendon sheath of one of the muscles that moves the eyeball (superior oblique muscle). It usually affects only one eye. It causes diplopia on looking upward and inward (towards the nose).
 
OCULAR NEUROPATHY is also rare. It is due to the RA vasculitis blocking the blood supply to a cranial nerve that innervates the muscles that move the eyeball. It can present as diplopia. This type of eye problem is most commonly caused by diabetes mellitus (sugar diabetes), however.
 
DRUGS used to treat RA can affect the eyes too. Steroids like prednisone can hasten the development of cataracts. Antimalarials like chloroquine and hydroxychloroquine can permanently damage the retina causing a loss of central vision. Chloroquine can also deposit in the cornea (keratopathy) causing visual problems like blurring and halos around lights but it is reversible. Gold can deposit in the cornea and conjunctiva but no symptoms or damage result.
 
In summary, episcleritis will not cause visual diplopia but Brown's syndrome (tendonitis of eyeball muscles) and ocular cranial neuropathy (loss of nerve supply to eyeball muscles) will cause visual diplopia. 
 
The peak incidence of rheumatoid arthritis (RA) in females is around the time of menopause. It does not seem to be related to a reduction in estrogen but there may be a relationship to the lack of progesterone and/or androgens ('male hormones' from the adrenal gland). Menopause may be associated with the worsening of the disease activity and the joint damage in pre-existing RA, but there is not enough evidence to be certain of this. The onset of RA is commoner when menopause occurs at a younger age.
 
Abstinence from smoking cigarettes may reduce the risk of developing RA in post-menopausal women.
 
One study showed that estrogen replacement in post-menopausal women did not protect against the occurrence of RA whereas another study did. One study showed a possible modest reduction in the risk of developing RA in the post-menopausal female with the brief use of progesterone but not of estrogen. However, there is no evidence that estrogen replacement therapy worsens RA.
 
There is a definite reduction in the frequency of fractures due to osteoporosis in post-menopausal women with RA who take estrogen replacements.

The 'painful ARCH syndrome' refers to chronic pain in the arch of the foot. The arch of the foot is the raised part of the midfoot on the inner aspect of the foot or instep. With this syndrome, pain occurs in the arch with walking and standing, rising up on the toes and ascending or descending stairs. It is often associated with a flat-foot (fallen arch). There may be strain of the spring ligaments (taut bands which join the bones in the arch) or the posterior tibial tendon (which keeps the arch elevated) or the plantar fascia ( a tight broad ligament running along the sole of the foot). Arthritis can also develop in the joints between the bones that make up the roof of the arch.
 
Treatment includes nonsteroidal anti-inflammatory drugs, soft supportive shoes that fit well and have a strong arch support and firm counter heel (athletic shoes), over-the counter arch pads and insoles, custom-made orthotics, ice, heat, ultrasound, taping, stretching the calf muscles, reduced weight bearing especially if barefoot and weight loss if overweight.
 
The 'painful ARCH syndrome' refers to chronic pain in the arch of the foot. The arch of the foot is the raised part of the midfoot on the inner aspect of the foot or instep. With this syndrome, pain occurs in the arch with walking and standing, rising up on the toes and ascending or descending stairs. It is often associated with a flat-foot (fallen arch). There may be strain of the spring ligaments (taut bands which join the bones in the arch) or the posterior tibial tendon (which keeps the arch elevated) or the plantar fascia ( a tight broad ligament running along the sole of the foot). Arthritis can also develop in the joints between the bones that make up the roof of the arch.
 
Treatment includes nonsteroidal anti-inflammatory drugs, soft supportive shoes that fit well and have a strong arch support and firm counter heel (athletic shoes), over-the counter arch pads and insoles, custom-made orthotics, ice, heat, ultrasound, taping, stretching the calf muscles, reduced weight bearing especially if barefoot and weight loss if overweigh.
 
Swollen leg is often a problem with the veins. The veins could be obstructed or the valves in the veins could be destroyed. The veins could be obstructed internally by  blood clots (phlebitis or deep vein thrombosis) that may have resulted from immobility following the sprained ankle. The veins could also be obstructed externally by the pressure of a mass like a popliteal (Baker's) cyst that sometimes forms at the back of an arthritic knee. Incompetent valves may result from varicose veins or previous blood clots. Lymphatic obstruction can be due to injury, infection or tumour, however, an ankle injury should not cause the entire leg to swell. Nor should capillary leaking from an ankle injury cause the entire leg to swell.
 
Synovitis of the knee;Synovitis refers to the inflammation of the synovial membrane that lines most joints. It is the basic process that results in an inflammatory arthritis. It has many different causes such as:
 
Infection: for example, bacteria like staph(ylococcus) and tuberculosis and viruses like German measles (rubella)

Crystals: for example, urate crystals in gout or calcium pyrophosphate crystals in pseudogout

Trauma: for example, an injury of or bleed into a joint or penetration of the joint by a plant thorn

Spondyloarthritis: for example, psoriatic arthritis, ankylosing spondylitis,  reaction to bowel or genital infection

Immune: for example, rheumatoid arthritis, lupus

Unknown cause: often referred to as non-specific synovitis.
Preventing a recurrence depends upon what is causing the synovitis; that is, to which of the above groups does the synovitis belong. The synovitis can be transient without recurrences, intermittently recurrent, persistent without joint damage or persistent with joint damage. If there is no specific cause that is treatable, then preventing injury or stress to the joint and keeping the associated muscles strong, might prevent a recurrence. But unfortunately, recurrences beyond our control still occur.
 
Ultrasound studies of the leg should be done to assess the blood flow in the veins and to detect the presence of cysts or masses behind the knee or in the groin. Manual and ultrasound examinations of the pelvis may be needed to rule out any pelvic disease that could obstruct the flow in the veins or lymphatics. An opinion from a vascular surgeon could help establish a diagnosis and a treatment plan. Treatment might include lying down 3 or 4 times during the day with the leg elevated and wearing compression stockings during the day.
 
Carpal tunnel syndrome is due to pressure on the median nerve as it crosses the  palm side of the wrist from the forearm to the hand. Symptoms include numbness, tingling, pain and weakness of the hand. There are many different cause of the nerve compression. In rheumatoid arthritis it is due to the inflammatory tissue (synovitis) from the wrist joint and the flexor tendons crossing it.
 
Surgery is the treatment required, and should be done soon before neurological loss is permanent or only partially recoverable. Endoscopic Surgery is a benefit to more rapid recovery, but inflammatory synovitis such as rheumatoid arthritis  is a relative contraindication because of possible poor visualization through the endoscope. Surgery should be done consecutively but not at the same time - the recovery seems to be delayed in those that have simultaneous surgery. While the first hand is recovering from surgery, the carpal tunnel on the other hand could be injected with cortisone and protected with a wrist splint as temporary measures.  
 
The inflammation of RA can damage the joints, discs and ligaments of the cervical spine (neck). The vertebrae become unstable and slip forward (subluxation).The discs  do not slip forward as in a 'slipped disc'. The 1st and 2nd cervical vertebrae are the most commonly involved but the lower cervical vertebrae may become involved later. As a result of this process, there can be neck pain, pressure on the spinal cord, nerve roots and arteries causing various neurological symptoms and forward pressure on the swallowing tube (esophagus) or windpipe (trachea). It would be involvement of the lower cervical vertebrae that could involve the trachea or esophagus. Another joint problem in RA that can affect the windpipe is inflammation of the cricoarytenoid joints (the joints that guard the entrance to the windpipe near the vocal cords).
 
This type of problem should be evaluated as soon as possible. Investigation may include opinions from a spine surgeon and ear, nose and throat specialist and x-rays and MRI of the neck and throat. The level of the cervical spine subluxation causing the problem will need to be determined. It will probably require realignment and surgical fusion.
 
The surgery requires a general anesthetic and intubation (putting a breathing tube into the trachea). The cervical spine can be operated on from the front or the back. It needs to be realigned and then fused in the corrected position. Bone grafts and metal components are used to keep the fusion stable. Some form of external stabilization will be used afterwards to keep the fused area from moving so that it can gradually fuse solidly. A halo is often put on at surgery to accomplish this. It is fixed to the skull and upper chest. Many weeks later it can be removed and a firm collar used instead. Eventually the collar is no longer required on a regular basis.
 
Complications can occur. There can be injury to the the nerve and vascular structures in the neck, infections, problems with healing of the surgical incision, fractures and anesthetic problems. Some neck movement may be lost. The collars and halos may cause some trouble opening the mouth and skin pressure problems. It is important to use a surgeon experienced in this type of surgery. 
 
Tendonitis ( common in RA ),refers to the inflammation or irritation of a tendon. A tendon is a thick fibrous cord or sinew that joins a muscle to a bone. When the muscle contracts, it pulls the tendon which moves the bone it attaches to. Some tendons are enclosed in a sheath that is lined by synovium, the same tissue that lines joints.
 
Tendonitis causes pain and stiffness which is increased by movement. If the sheath of a tendon is inflamed, it often swells. Tendonitis is usually temporary but sometimes it can be recurrent or chronic. Unlike arthritis, it does not cause deformity. It can restrict motion and alter function.
 
The commonest cause of tendonitis is an injury or overuse. It also occurs with rheumatoid arthritis, psoriatic arthritis and reactive arthritis.  It can also be due to infection or gout. It may be associated with thyroid conditions or diabetes mellitus
 
There are many different causes of bunions. Rheumatoid arthritis is one of them. Bunions are made worse by flat feet, high heeled shoes and shoes with pointed or narrow toe boxes. In rheumatoid arthritis, the damage to the joints that make up the balls of the second to fifth toes increases the instability and reduces the buttressing of the big toe. As a result, the bunion will worsen.
 
Surgery should be considered when the symptoms of the bunion are not controlled by properly fitted shoes with wide and deep toe boxes and insoles. The symptoms include pain, difficulty bearing weight, inability to find shoes that fit and skin breakdown and infection over the bunion.
 
Three types of surgery to the big joint of the big toe (first metatarsophalangeal joint or 1st MTP joint) are available to treat bunions:  Resection of the joint (Keller procedure). In this procedure, the ends of the bone making up the joint are resected with an improvement of the angle of the big toe. Bunions recur in up to 53% of cases. Silastic joint implant. In this type of surgery, the big toe is straightened and a plastic implant is put into the joint. It is not uncommon for the bunion to return. Fusion of the joint. In this type of operation, the big toe is straightened and then fused so that it does not move. The bunion does not recur. Furthermore there is better pain relief and better weight bearing than with the other 2 types of surgery. In summary, bunions result from rheumatoid arthritis. If the problems caused by the bunions cannot be controlled to your satisfaction by simple measures then fusion of the big joint on the big toe is the surgery of choice.  The chances of the bunion recurring with this procedure are almost nil. 
 
The small joints of the spine in the neck (cervical spine) are inflamed. The resulting inflammatory tissue grows into the spinal canal narrowing it. Sometimes this tissue can press on the spinal cord and the nerves that arise from it preventing them from working properly.  At the same time, the inflammation damages these joints so that they become unstable and prone to dislocation. The vertebral bones  become thin or osteoporotic making them susceptible to fracture. The vertebral arteries, which supply the back half of the brain, travel through these vertebra and the more out of position these vertebra get, the more likely they are to  kink the artery and block the blood flow to the brain.
 
Therefore, manipulation of the neck could cause these unstable vertebra to shift or dislocate. As a result the spinal canal could narrow further putting  more pressure on the spinal cord and nerves at that level and possibly kinking the vertebral arteries to slow the flow of blood going to the brain.  The pressure on the spinal cord could cause paralysis of the lower body and legs and sometimes the upper body and arms as well. The reduced blood flow to the brain could result in a stroke. Also a forceful manipulation could fracture one of the osteoporotic vertebra.
 
IF YOU HAVE RHEUMATOID ARTHRITIS, DO NOT HAVE YOUR NECK MANIPULATED
 
Arthritis of the lungs is a misnomer. It refers to various patterns of inflammatory and immune lung problems that occur in association with certain rheumatic diseases. Such diseases include rheumatoid arthritis, systemic lupus erythematosus,  scleroderma, Sjogren's syndrome, polymyositis and dermatomyositis and various forms of vasculitis such as Wegener's granulomatosis. Lung involvement in these diseases is not rare but does vary from being very common in some like scleroderma and less common in others like rheumatoid arthritis.
 
These conditions can affect different parts of the lung in different combinations and severities.  These parts include the small airways (bronchioles), the lung tissues (alveolar sacs and interstitial spaces between the air and circulating blood), the small and large blood vessels and the lining of the chest wall and covering of the lung (pleura).
 
Inflammation of the bronchioles is called bronchiolitis. The symptoms are fever, cough and shortness of breath. It often improves with treatment but rarely may progress to lung failure.
 
Inflammation of the alveolar sacs is called pneumonitis. It appears as infiltrates in the lung tissue on the chest X-ray. The symptoms are shortness of breath, cough, sharp chest pain with breathing, fever and rapid breathing. It usually recovers with treatment but sometimes may progress to scarring of the lung interstitial tissue and even to lung failure. Sometimes nodules and cavities may form in the lung but they rarely cause symptoms.
 
Inflammation of the interstitial space is known as interstitial pneumonitis and may progress to interstitial fibrosis or scarring. The symptoms include dry cough and shortness of breath with changes seen on CT scans of the lung. The inflammatory phase responds to treatment but the fibrotic stage does not. Sometimes it may progress to lung failure.
 
Inflammation of the small blood vessels is referred to as pulmonary vasculitis. It may present with fever, shortness of breath, coughing up of blood and infiltrates on the chest  X-ray. This is generally a severe acute problem that could cause death but aggressive treatment can lead to recovery.
 
Involvement of the larger arteries leads to their narrowing with an increase in the blood pressure of these pulmonary arteries. It is referred to as pulmonary hypertension. It can result in shortness of breath, chest pain on exertion, right sided-heart failure and lung failure.
 
Inflammation of the pleura (pleurisy or pleuritis) causes sharp chest pain on breathing with difficulty in breathing due to the pain. Sometimes fluid will form between the pleura covering the lung and the pleura lining the inner chest wall. This is called a pleural effusion. If large enough, it could cause shortness of breath. Complete recovery usually occurs with treatment.
 
In most cases treatment is available. Treatment usually includes corticosteroids and immunosuppressants such as azathioprine, cyclophosphamide and cyclosporin.  
 
Some RA patiens develop what is called "secondary "Sjogren's syndrome that leads to dryness of the mucocutaneous tissues. The sweat glands may be involved resulting in reduced sweating and dry skin-- the opposite of the excessive sweating you are noticing in your feet. I cannot relate the excesive sweating in your feet to the Sjogren's syndrome.  Prednisone may cause excessive sweating but it is usually generalized.
 
Painful skin lesions occur in Sjogren's syndrome as a result of vasculitis (inflammation of blood vessels) and tend to occur most commonly on the legs. Before changing therapy, a dermatologist should confirm the diagnosis of your skin lesions. If they are confirmed to be due to the vasculitis of Sjogren's syndrome, then higher doses of prednisone may be needed and/or an antimalarial such as hydroxychloroquine could be added and/or an immunosuppressant such as azathioprine or methotrexate etc. could be added.
 
Vasculitis is rare in rheumatoid arthritis. One other thing is that RA patients,especially the older patients may develop "secondary osteoarthritis ( OA) due to age advancement and the constant on-going ravages of  rheumatoid arthritis that can be produced.
 
About 10 to 25% of persons with rheumatoid arthritis have no detectable rheumatoid factor in their blood. The reason for this is not clear. Because rheumatoid arthritis may have several different causes and because it occurs in persons with different genetically determined immune systems, it will not be manifested  in the same way in everyone. In addition, there are other types of inflammatory arthritis, not associated with rheumatoid factor, that can resemble rheumatoid arthritis eg. psoriatic arthritis and systemic lupus erythematosus. It is important to make the correct diagnosis.  Rheumatoid arthritis should be treated as soon as possible in order to retard joint damage. A rheumatologist should be consulted to clarify the diagnosis and recommend treatment.
 
Seropositive RA (RF) is usually associated with more severe RA,but again,there are exceptions to everything.
 

Patients with rheumatoid arthritis (RA) appear to be at increased risk of myocardial infarction (MI), congestive heart failure (CHF), and probably stroke, according to a report published in the January issue of The Journal of Rheumatology.
 
Previous reports have shown a link between RA and cardiovascular disease mortality. However, cardiovascular disease morbidity and the risk of cardiovascular events in patients with rheumatoid arthritis have not been investigated.
 
Dr. Frederick Wolfe, from the Arthritis Research Center Foundation in Wichita, Kansas, and colleagues compared the incidence of adverse cardiovascular events in 9093 patients with RA and in 2479 patients with osteoarthritis. The patients completed a survey regarding past and current medical problems.
 
On multivariate analysis, RA patients were more than twice as likely as osteoarthritis patients to have experienced an MI. In addition, RA patients were 43% more likely to have a history of CHF and 70% more likely to report current stroke. For RA patients, the lifetime prevalences of MI, CHF, and stroke were 4.14%, 2.34%, and 3.02%, respectively.
 
"To our knowledge, this is the first study examining cardiovascular and/or cerebrovascular disease morbidity among RA patients," the investigators note.
The present findings indicate that RA is, in fact, associated with increased cardiovascular disease morbidity. "As such, the effects of RA on morbidity as well as mortality should be accounted for in estimates of the RA burden of illness and should be considered in future studies examining therapies for RA," the authors conclude