Rheumatoid Arthritis
An autoimmune synovitis in which loss of tolerance to self-antigens drives a chronic inflammatory pannus that erodes cartilage and bone, symmetrically, from the small joints inward.
In a nutshell
Loss of tolerance to citrullinated self-proteins drives autoantibody-mediated synovitis that thickens into destructive pannus, eroding cartilage and bone. Because the process is autoimmune and systemic, disease is symmetrical, affects small joints early, and is treated by suppressing the immune drivers as early as possible.
Classic presentation
A patient with weeks of symmetrical pain and swelling of the hands and feet, morning stiffness lasting over an hour that improves with activity, and fatigue, with positive anti-CCP antibodies.
Key points
- Anti-CCP antibodies are specific and can precede symptoms by years, reflecting the autoimmune origin of disease before joints are clinically involved.
- Pannus formation, not mechanical stress, drives cartilage and bone erosion: this is why rheumatoid arthritis causes erosions rather than osteophytes.
- Morning stiffness over 30 minutes that improves with movement is the mirror image of osteoarthritis, where pain worsens with use.
- Early DMARD therapy within the 'window of opportunity' prevents irreversible erosive damage: delay worsens long-term joint outcome.
- Extra-articular features (nodules, vasculitis, pulmonary and cervical spine involvement) reflect the systemic nature of the autoimmune process.
First-line investigation
Rheumatoid factor and anti-CCP antibodies alongside CRP/ESR, with urgent rheumatology referral for suspected persistent synovitis.
First-line management
Early conventional DMARD therapy, typically methotrexate, started as soon as possible after diagnosis, with short-term corticosteroid bridging.
Exam traps
- A seronegative result does not exclude rheumatoid arthritis: a minority of patients are rheumatoid factor and anti-CCP negative.
- Distal interphalangeal joint involvement points away from rheumatoid arthritis and towards osteoarthritis or psoriatic arthritis.
- Stiffness that improves with activity is rheumatoid arthritis; stiffness that worsens with activity is osteoarthritis.
- Do not delay DMARD referral awaiting radiographic erosions: early ultrasound/MRI changes and clinical synovitis are enough to act on.
Educational content pending clinical review. Not medical advice.