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Extra-Articular Features In RA

Rheumatoid Arthritis (RA) is a chronic,systemic,inflammatory disease that chiefly affects the synovial membranes of multiple joints in the body. Because the disease is systemic,there are many extra-articular features of the disease as well.
 
Although the joints are almost always the principal focus of rheumatoid arthritis,other organ systems may also be involved. Extra-articular manifestations of rheumatoid arthritis occur most often in seropositive patients with more severe joint disease,but they can occur in all types.
 
It is interesting to note that  EAF's can occur in later stages of the disease where there is little active synovitis ("burnt-out" disease).  In contrast to the predilection of RA for women,EAF manifestations of the disease are more common in men.Since RA can cause EAF's,it can be viewed as a disease that affects the whole body not just the joints.
 
The most common EAF in RA is tendonitis. Tendonitis is inflamation of the tendon sheath. Tendons,similar to joints,are covered with a sheath-like membrane (the synovium). The synovium becomes inflamed and swollen in RA patients.
 
Tendonitis occurs most frequently in the hands, but can occur in wrists, elbows,shoulders,around the knees,and in the feet. This helps distinguish  it from other types of the many arthritis, like osteoarthritis, where extra-articular features are absent.
 
 In patients with moderate or severe types of RA,firm non-tender nodules develop under the skin,particularly in areas subject to pressure such as elbows, feet,or buttocks. These nodules are a distinguishing sign of RA usually, apparent in moderate and severe but not limited to type.Nodules rarely occur in arthritic diseases other then RA.
 
Heart-- Inflammation occurs most commonly in the pericardium,a sac-like structure that surrounds the heart. The inflammation causes pain and sometimes an increase in fluid,which may compress the heart and impair function. This type of inflammation (pericarditis) can be detected by a simple occasional test.(ultrasound). Rarely,does nodules cause scarring within the heart walls, arteries, or on the valves of the heart. 
 
Lungs --In RA,inflammation of the lungs is common.The most common site of inflammation is in the pleurae,which is situated between the lungs and the chest cavity.Most patients involved will experience pain when breathing in or out. In some patients,the pleural space which separate the chest walls and lungs,fills with liquid.
 
Occasionaly inflammation occurs throughout the lungs. This condition  is called fibrosis and leads to lung scarring Symptoms are shortness of breath and cough.Breathing tests help to confirm  a diagnosis of fibrosis.
 
Nervous System--RA can affect  the nervous system. The most common cause  arise from the compression of the nerves. This happens frequently in the hands,and is called carpal tunnel syndrome. The carpel tunnel is a narrow shallow tunnel in the wrist through which all of the important nerves, tendons, and blood supply to the hand pass.
 
Inflammation within this tunnel,caused by arthritis,or other conditions, creates pressure on one of the nerves passing through it,which leads to irritation. Pressure on the nerve results in numbness,in the palm of the hand and the second,third,and fourth fingers. Generally the numbness in the hands is worse at night. C.P.S. is not limited to RA.
 
RA can also affect nerves in other parts of the body. If  RA causes damage to the joints in your neck,it can lead to bone shifts and compression of the spinal cord ot the nerves that exit it. The result is nunbness in the arms and legs.
 
Blood vessels-- In rare cases,RA can be so wide spread that it causes inflammation within the linings of blood vessels. Blood vessels inflammation is called vasculitis. Damage to blood vessels or their closure can lead to damage in the organs that the blood vessels feed. Vasculitis is serious because it could damage organs such as the kidneys or the heart.
 
Eyes -- RA can affect the eyes,either directly by inflammation or indirectly  by damaging the tear ducts. When the tear ducts are damaged  their secreations decrease,and dry eyes will result, particularily at night. Inflammation of the cornea can cause distorted vision and sometimes damage the eye. Some RA patients also have Sjorgens sydrome which is the syndrome described.

Many patients with the more severe type of RA feel ill,much as though they have a chronic bad flu. Patients feel tired,have no energy,feel nauseated, lose their appetite and some lose weight. These symptoms are typical of RA and are called constitutional features.
 
All patients with RA feel unwell,but patients with moderate-severe disease feel the most unwell. Like extra-articular features,the severity of these symptoms  helps to separate RA from other forms of arthritis.
 
Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First,there is no single test for the disease.In addition, symptoms differ from person to person and it will be more severe in some people than others. Also,symptoms can be similar to those of other types of arthritis and joint conditions,and it may take some time for other conditions to be ruled out as possible diagnosis. Finally,the full range of symptoms may develop over time,and only a few symptoms  may be present at onset of disease. As a result physicians use a variety of methods to diagnose the disease and to rule out other conditions.
 
The patient's description of symptoms and when and how they began will assist the physician. Good communication between patient and physician is essential.For example,the patient's description of pain, stiffness,and joint function and how these change over time is critical to the physicians initial assessment of the disease and his or her assessment  of how the disease changes or progresses.

Tendonitis is the inflammation,irritation or microscopic tearing of a tendon-a band of tough,flexible,fibrous tissue that connects musle to bone. Tendons range in size from the delicate,minute bands of the hands to the heavy rope-like cords that anchor the calf or thigh muscles.
 
In most cases,tendonitis occurs because of overuse or overload. Although tendonitis may affect tendons anywhere in the body,the most common sites are the shoulder,elbow,knee,wrist.and hand. In general, tendonitis produces pain in the tissues-surrounding a joint,especially after excissive use of the joint during play or work In some cases,there may be weakness at the involved joint,and the affected area may be red,swollen,and warm to the touch.
 
Your doctor may also ask you to perform specific limb maneuveres, such  as raising your arm above your head or bending your wrist. These maneuveres may be may be painful,but important and necessary as part of the diagnostic process because they tell the doctor which tendons are affected. In selected patients,blood tests may be necessary to rule out other causes of inflammation around the joints,such as gout or RA.
 
Bursitis: The bursa is a sac-like membrane near the joint space that acts as a cushion between the fibrous muscle,and bony prominences. Without the bursa,friction caused by movement would impede flexibility in the joints. bursitis,the inflammation of the bursa,is a common condition that occurs often when a specific joint is overused,in rarer cases include gout and infection. One form of bursitis called "housemaid's knee" occurs when the bursa in the front of the kee swells,because to much weight has been put on the joint,over a long time-period.
 
Bursitis is more common in overweight,older,and diabetic persons, although it commonly develops in healthy people,without a clear reason. Pain may occur around such joints as the elbows, hip, shoulder, big-toe.and knee,especially if pressure is applied. to the area or with use. Redness,warmth,and swelling are less common,and may indicate infection.
 
If the doctor suspects that gout or infection is the cause of bursitis,he or she may recommend that you undergo a minor procedure in which a sample of the fluid is removed from the bursa for analysis.

Felty's syndrome is a very rare complication of RA-it occurs in less than 1 % of people with long-standing disease. This syndrome is associated with a low number of white blood cells and an enlarged spleen,which means your body cannot fight off infections as it used to. The platelet count might also be decreased,which means your blood may not clot as well and you may run the risk of excessive bleeding.
 
Skin ulcers and dark patches of skin are other sign's of  Felty's syndrome. Felty's syndrome usually clears up after DMARD treatment,if it does not,you may have to get your spleen removed.
 
Vasculitis is also not common,it usually occurs in people who have a high RF factor. Vasculitis can affect blood vessels in any part of the body. In mild cases, it prevents adequate blood flow to the skin,resulting in skin ulcers. These sores can be treated with washing-carefully and gently with antiseptic soap,and usually,clears up with DMARD treatment.
 
If vasculitis affects the vessels of the brain,however,it is more serious-it can cause strokelike symptoms,and can be fatal. Fortunately this is not a common occurance. Vasculitis can also affect the arteries of the lungs,heart, intenstines, and kidneys,interfearing with the normal functioning of these organs.
 
 Rheumatoid  vasculitis can cause the small blood vessels in your hands, fingers,feet,or toes to become completely blocked up,preventing blood flow. The affected area may have to be amputated. The serious forms of vasculitis is usually treated with stronger doses of corticosteriods or much stronger chemotherapeutic agents,or both in combination.

 
Eye dryness leading to an itchy,"gritty" feeling is characteristic of Sjogren's syndrome This happens in about 25 % of people with RA. It is referred to as "secondary "Syogren's syndrome. It is also seen in other arthritic conditions including SLE. It occurs just as often in people who have no arthritis-primary Sjorgren's.
 
Dryness occurs because the tear gland of the eye is affected by low-grade inflammation,and tear tear production drops. People with Sjogren's syndrome (or "sicca syndrome") often also notice marked dryness of the mouth and in the case of women,the vagina.
 
Sometimes the eyes are red and painful and there may be sign of significant corneal damage in Sjogren's syndrome. They may also occur in RA (where the eye is usually painless ) or in the seronegativee spondylarthritis (such as ankylosing spondylitis and psoriatic arthritis),where they may be quite irritable.
 
 Photophobia (discomfort from bright lights) can be a real problem. Red eyes tend to clear up,but an eye specialist should be consulted,especially if pain or blurring of vision occurs.
 

Changes in vision are uncommon. Those that complicate the red eyes of Sjorgren's syndrome,tend to occur slowly. Even slower to develop is the "silent" loss of vision seen in some forms of juvenile RA-which is why monitoring by a eye specialist is important.
 
A sudden loss of vision,or double vision or blurring of vision,is a serious symptom of temporal arteritis. Antimalarial drugs should never lead to vision changes if taken as prescribed,although the eyes should be still checked by an eye specialist at least twice a year. Much more likely is the possibility of "speeded-up" development of cataracts when patients are on long-term corticosteroid treatment
 
The use of Plaquenil as an antimalarial agent has further  minimized eye problems caused by those types of drugs.
 

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.