复旦大学临床医学专业：《内科学》课程教学资源（课件讲义，双语版）类风关（姜林娣）

RHEUMATOID ARTHRITIS (RA) Jiang Lindi (Zhongshan Hospital)

RHEUMATOID ARTHRITIS （RA） Jiang Lindi (Zhongshan Hospital)

What is rA? RA is a chronic polyarticular inflammatory arthritis that involves not only small joints of the hands and feet but also systemic organs √ Pathologic change: chronic synovitis with pannus(血管 翳) formation It will cause bony destruction, deformation, disability if joint inf lammation repeatedly occur v RF is present in the sera of more than 75%of patients Y The prevalence rate of ra has been estimated to be 0. 32%-0 36% in China, Women appear to be affected three times more commonly than men

What is RA? ✓ RA is a chronic polyarticular inflammatory arthritis that involves not only small joints of the hands and feet but also systemic organs. ✓ Pathologic change: chronic synovitis with pannus (血管 翳)formation. ✓ It will cause bony destruction, deformation, disability if joint inflammation repeatedly occur. ✓ RF is present in the sera of more than 75%of patients. ✓ The prevalence rate of RA has been estimated to be 0.32%-0.36% in China, Women appear to be affected three times more commonly than men

ETIOLOGy 1. Infectious agents: Epstein-Barr virus mycoplasma, macobacteria, retroviruses T lymphocyte and macrophage activation B lymphocyte activation Change of the gene expression Molecular mimicry

ETIOLOGY 1. Infectious agents: Epstein-Barr virus, mycoplasma, macobacteria, retroviruses – T lymphocyte and macrophage activation – B lymphocyte activation – Change of the gene expression – Molecular mimicry

2. Genetic factors Y A high incidence among monozygotic twins(30% a50%),first-degree relative Role of hla-dr4 in the susceptibility to and severity f ra 70%RA patients, a relative risk of having ra with HLA DR4 of 4 to 5 The susceptibility epitope( shared epitope共同表位) QKRAA或 QRRAA It was considered to be related with the severity of established ra

2. Genetic factors ✓ A high incidence among monozygotic twins (30% ~50%),first-degree relative ✓ Role of HLA-DR4 in the susceptibility to and severity of RA − 70% RA patients ，a relative risk of having RA with HLA￾DR4 of 4 to 5 − The susceptibility epitope (shared epitope 共同表位): QKRAA或QRRAA − It was considered to be related with the severity of established RA

3. Gender Predominance in women Improvement or remission of ra during pregnancy 4.Induced factors: tiredness, humidity cold, mulnutrition psychical stimuli

3. Gender: – Predominance in women – Improvement or remission of RA during pregnancy 4.Induced factors: tiredness, humidity, cold, mulnutrition, psychical stimuli

PATHOLOGY antigen: HLA-DR( QKRAA)、 heat shock protein、IgG、 type ii colga antigen processing macrophages +MHCII-peptide complexes resentation Tce‖l cytokine(I-1、2、3、4、6、TNF、r-INF) B cell activation Immune damage RF and other antibody collagenase、 stromelysin cartilage and bone destruction extra-articular symptom

antigen :HLA-DR(QKRAA)、heat shock protein、IgG、type II collagen antigen processing macrophages +MHCII-peptide complexes presentation T cell cytokine（IL-1、2、3、4、 6、TNF、r-INF） B cell activation immune damage RF and other antibody collagenase、stromolysin cartilage and bone destruction extra-articular symptom PATHOLOGY

类风湿性关节炎滑膜病理 PATHOLOGIC FINDING 1. chronic synovitis In acute phase: effusion and cell infiltration In chronic phase the number of a type cell remarkably increases the pannus erodes cartilage, bone, ligaments and tendons 2. extra-articular: vasculitis, rheumatoid nodule

PATHOLOGIC FINDING 1. chronic synovitis In acute phase: effusion and cell infiltration In chronic phase: the number of A type cell remarkably increases the pannus erodes cartilage, bone, ligaments and tendons. 2. extra-articular：vasculitis、rheumatoid nodule

CLINICAL FAETURES Y The usually age at onset is 35-50 years v the ratio of female to male is 3 1 y The onset of ra is usually insidious Y Systemic symptom of fatigue, malaise, fever weight loss may be seen

CLINICAL FAETURES ✓ The usually age at onset is 35-50 years ✓ The ratio of female to male is 3:1 ✓ The onset of RA is usually insidious ✓ Systemic symptom of fatigue, malaise, fever, weight loss may be seen

1. Joint manifestation (1)morning stiffness stiffness persisting for over 30 minutes is prominent in the morning or after daytime activity and subsides during the day The persisting length of morning stiffness is associated with the degree of joint inflammation The duration of morning stiffness is used as the index of disease activity

1. Joint manifestation （1）morning stiffness – stiffness persisting for over 30 minutes is prominent in the morning or after daytime activity and subsides during the day – The persisting length of morning stiffness is associated with the degree of joint inflammation. – The duration of morning stiffness is used as the index of disease activity

腕关节 (2) pain and tenderness: painful on rest location: small( PIP, MCP), symmetric joint 掌指关节 characteristic: persisting, dull or swollen pain 指间关节 (3)swelling: synovial proliferation, effusion swelling of soft tissue (4)articular deformity: ulnar deviation of the fingers, swan-neck" deformity, atrophy of skin and muscle(see figurel-5 (5) involvement of special joint: atlantoaxial subluxation, shoulders, temporomandibular joint, hips

（2）pain and tenderness： painful on rest location：small (PIP,MCP), symmetric joint characteristic：persisting、dull or swollen pain （3）swelling：synovial proliferation, effusion, swelling of soft tissue （4）articular deformity：ulnar deviation of the fingers, “swan-neck” deformity, atrophy of skin and muscle (see figure1-5) （5）involvement of special joint: atlantoaxial subluxation，shoulders, temporomandibular joint, hips