What is Arthritis?

Arthritis is often referred to as a single disease. In fact, it is an umbrella term for more than 100 medical conditions that affect the musculoskeletal system, specifically joints where two or more bones meet.

Arthritis-related problems include pain, stiffness, inflammation and damage to joint cartilage (the tissue that covers the ends of bones, enabling them to move against each another) and surrounding structures. This can result in joint weakness, instability and deformities that can interfere with the most basic daily tasks such as walking, driving a car and preparing food.


As the population ages, the number of people with arthritis is growing. .There is a widely held belief that arthritis is simply a consequence of age, the pain of growing old. But it is not a natural part of ageing. In fact 2.4 million of all people suffering from the disease are of working age .


Research suggests that early intervention can delay the onset of the disease and may reduce the number of cases of osteoarthritis by about 500,000 within 15 years.


While there are about 100 forms of arthritis, the three most significant - osteoarthritis, rheumatoid arthritis and gout - account for more than 95 per cent of cases worldwide.


Arthritis is not yet curable. While the condition is usually manageable, it invariably impacts on a patient's quality of life and includes varying degrees of discomfort and pain.

The most common forms of arthritis are:

• Osteoarthritis
• Rheumatoid arthritis
• Gout
• Ankylosing spondylitis
• Juvenile arthritis
• Systemic lupus erythematosus (lupus)
• Scleroderma

Rheumatic fever

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Rheumatic fever is an inflammatory disease that occurs following a Streptococcus pyogenes infection, such as strep throat or scarlet fever. Believed to be caused by antibody cross-reactivity that can involve the heart, joints, skin, and brain, the illness typically develops two to three weeks after a streptococcal infection. Acute rheumatic fever commonly appears in children between the ages of 6 and 15, with only 20% of first-time attacks occurring in adults. The illness is so named because of its similarity in presentation to rheumatism.

Diagnosis

Major criteria

Modified Jones criteria were first published in 1944 by T. Duckett Jones, MD. They have been periodically revised by the American Heart Association in collaboration with other groups. According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre or DNAase.Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.

most severe complication in rheumatic heart disese.

• polyarthritis: a temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards.
• Carditis: inflammation of the heart muscle which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur.
• Subcutaneous nodules: painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.
• Erythema marginatum: a long lasting rash that begins on the trunk or arms as macules and spreads outward to form a snake like ring while clearing in the middle. This rash never starts on the face and it is made worse with heat.
• Sydenham's chorea (St. Vitus' dance): a characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease for at least three months from onset of infection.

erythema.

subcutaneous nodules.

Minor criteria

• Fever of 38.2–38.9 °C (101–102 °F)
• Arthralgia: Joint pain without swelling (Cannot be included if polyarthritis is present as a major symptom)
• Raised erythrocyte sedimentation rate or C reactive protein
• Leukocytosis
• ECG showing features of heart block, such as a prolonged PR interval (Cannot be included if carditis is present as a major symptom)
• First Degree AV-Block 
• Previous episode of rheumatic fever or inactive heart disease

Other signs and symptoms

• Abdominal pain
• Nose bleeds
• Preceding streptococcal infection: recent scarlet fever, raised antistreptolysin 0 or other streptococcal antibody titre, or positive throat culture.

Pathophysiology

Group A streptococcus pyogenes has a cell wall composed of branched polymers which sometimes contain M protein that are highlyantigenic. The antibodies which the immune system generates against the M protein may cross react with cardiac myofiber protein myosin,heart muscle glycogen and smooth muscle cells of arteries, inducing cytokine release and tissue destruction. However, the only proven cross reaction is with perivascular connective tissue.^{[citation needed]} This inflammation occurs through direct attachment of complement and Fc receptor-mediated recruitment of neutrophils and macrophages. Characteristic Aschoff bodies, composed of swollen eosinophilic collagen surrounded by lymphocytes and macrophages can be seen on light microscopy. The larger macrophages may become Aschoff giant cells. Acute rheumatic valvular lesions may also involve a cell-mediated immunity reaction as these lesions predominantly contain T-helper cells and macrophages.

Rheumatic fever is a systemic disease affecting the peri-arteriolar connective tissue and can occur after an untreated Group A Beta hemolytic streptococcal pharyngeal infection. It is believed to be caused by antibody cross-reactivity. This cross-reactivity is a Type II hypersensitivityreaction and is termed molecular mimicry. Usually, self reactive B cells remain anergic in the periphery without T cell co-stimulation. During a Streptococcus infection, mature antigen presenting cells such as B cells present the bacterial antigen to CD4-T cells which differentiate into helper T₂ cells. Helper T₂ cells subsequently activate the B cells to become plasma cells and induce the production of antibodies against the cell wall of Streptococcus. However the antibodies may also react against the myocardium and joints,producing the symptoms of rheumatic fever.

In acute rheumatic fever, these lesions can be found in any layer of the heart and is hence called pancarditis. The inflammation may cause a serofibrinous pericardial exudate described as "bread-and-butter" pericarditis, which usually resolves without sequelae. Involvement of the endocardium typically results in fibrinoid necrosis and verrucae formation along the lines of closure of the left-sided heart valves. Warty projections arise from the deposition, while subendothelial lesions may induce irregular thickenings called MacCallum plaques.

Chronic rheumatic heart disease is characterized by repeated inflammation with fibrinous resolution. The cardinal anatomic changes of the valve include leaflet thickening, commissural fusion and shortening and thickening of the tendinous cords.

Prevention

Prevention of recurrence is achieved by eradicating the acute infection and prophylaxis with antibiotics. The American Heart Association recommends daily or monthly prophylaxis continue long-term, perhaps for life.

Treatment

The management of acute rheumatic fever is geared toward the reduction of inflammation with anti-inflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for strep throat should also be treated with antibiotics. Aspirin is the drug of choice and should be given at high doses of 100 mg/kg/day. One should watch for side effects like gastritis and salicylate poisoning. In children and teenagers, the use of aspirin and aspirin-containing products can be associated with Reye's syndrome, a serious and potentially deadly condition. The risks, benefits and alternative treatments must always be considered when administering aspirin and aspirin-containing products in children and teenagers. Ibuprofen for pain and discomfort and corticosteroids for moderate to severe inflammatory reactions manifested by rheumatic fever should be considered in children and teenagers. Steroids are reserved for cases where there is evidence of involvement of heart. The use of steroids may prevent further scarring of tissue and may prevent development of sequelae such as mitral stenosis. Monthly injections of longacting penicillin must be given for a period of five years in patients having one attack of rheumatic fever. If there is evidence of carditis, the length of Penidure therapy may be up to 40 years. Another important cornerstone in treating rheumatic fever includes the continual use of low-dose antibiotics (such as penicillin, sulfadiazine, orerythromycin) to prevent recurrence.

Infection

streptococcus bacterai

Patients with positive cultures for Streptococcus pyogenes should be treated with penicillin as long as allergy is not present. This treatment will not alter the course of the acute disease.

The most appropriate treatment stated in the Oxford Handbook of Clinical Medicine for rheumatic fever is benzylpenicillin.

Inflammation

Patients with significant symptoms may require corticosteroids. Salicylates are useful for pain.

Heart failure

Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure: diuretics and digoxin. Unlike normal heart failure, rheumatic heart failure responds well to corticosteroids.

Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis (JRA) is a term used to describe a common type of arthritis in children. It is a long-term (chronic) disease resulting in joint pain and swelling.

Causes, incidence, and risk factors

The cause of JRA is not known. It is thought to be an autoimmune illness. This means the body's immune system mistakenly attacks and destroys healthy body tissue.

Polyarticular Juvenile Rheumatoid Arthritis

JRA usually occurs before age 16. Symptoms may start as early as 6 months old.

It is divided into several types:

• Systemic (bodywide) JRA involves joint swelling or pain, fevers, and rash. It is the least common type.
• Polyarticular JRA involves many joints. This form of JRA may turn into rheumatoid arthritis. It may involve five or more large and small joints of the legs and arms, as well as the jaw and neck.
• Pauciarticular JRA involves four or less joints, most often the wrists, or knees. It also affects the eyes.

Symptoms

Symptoms of JRA may begin with a swollen joint, limping, a spiking fever, or a new rash.

swollen joints.

Symptoms can include:

• Joint stiffness and pain
• Limited range of motion
• Warm, swollen, or red joints
• A child may stop using an affected limb 

Body-wide JRA symptoms:

• Fever, usually high fevers every day
• Rash (trunk and extremities) that comes and goes with the fever
• Pale skin
• Looks sick
• Swollen lymph nodes (glands)

JRA can also cause eye problems called uveitis, iridocyclitis, or iritis. There may be no symptoms, or the person may have:

• Red eyes
• Eye pain, which may get worse when looking at light (photophobia)
• Vision changes

Signs and tests

The physical examination may show swollen, warm, and tender joints that hurt to move. The child may have a rash. Other signs include:

• Swollen liver
• Swollen spleen
• Swollen lymph nodes

Blood tests that may be done include:

• Rheumatoid factor
• Erythrocyte sedimentation rate (ESR)
• ANA
• Complete blood count (CBC)
• HLA antigens for HLA B27

Any or all of these blood tests may be normal in patients with JRA.

The health care provider may place a small needle into a swollen joint to remove fluid. This can help to find the cause of the arthritis and help relieve pain, too. Sometimes, the health care provider will inject steroids into the joint to help reduce swelling.

Other tests that may be done include:

• X-ray of a joint
• Bone scan
• X-ray of the chest
• ECG
• Eye exam by an ophthalmologist (should be done on a regular basis, even if there are no eye symptoms)

Treatment

When only a small number of joints are involved, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen may be enough to control symptoms.

Corticosteroids may be used for more severe flare-ups to help control symptoms.

Children who have arthritis in many joints, or who have fever, rash, and swollen glands may need other medicines. These medicines are called disease-modifying antirheumatic drugs (DMARDs). They can decrease or prevent swelling in the joints or body. DMARDs include:

• Methotrexate
• Biologic drugs, such as such as etanercept, infliximab, and related drugs

It is important for children with JRA to stay active and keep their muscles strong.

Exercise will help keep their muscles and joints strong and mobile.

• Walking, bicycling, and swimming may be good activities.
• Children should learn to warm up before exercising.
• Talk to the doctor or physical therapist about exercises to do when your child is having pain.

Support and help for children who have sadness or anger about their arthritis is also very important.

Some children with JRA may need surgery, including joint replacement.

Expectations (prognosis)

Long periods with no symptoms are more common in those who have only a small number of joints involved. Many children with JRA eventually go into remission with very little loss of function and joint damage.

The greater the number of joints affected, the more severe the disease and the less likely that the symptoms will eventually go into total remission.

Children with JRA who have many joints involved, or who have a positive rheumatoid factor are more likely to have chronic pain, disability, and poor school attendance. The greater the number of joints affected, the more severe the disease and the less likely that the symptoms will eventually go into total remission.

Complications

chronic uveitis.

• Wearing away or destruction of joints (can occur in patients with more severe JRA)
• Slow rate of growth
• Uneven growth of an arm or leg
• Loss of vision or decreased vision from chronic uveitis (this problem may be severe, even when the arthritis is not very severe)
• Anemia
• Swelling around the heart (pericarditis)
• Chronic pain, poor school attendance

Prevention

There is no known prevention for JRA.

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