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Chapter 8: Seropositive arthritis 361

Heart: Eyes:
Cardiac involvement includes Sjogren's syndrome causes dry gritty
pericarditis (10% clinically evident). eyes.
Myocarditis does occur but is rare. Scleritis and episcleritis present as an
acute, red painful eye.
Degradation of scleral collagen (blue
Lung: appearance) which rarely may
Pleural involvement is common and progress to perforation (scleromalacia
may result in pain and effusions. perforans)
Interstitial fibrosis, lung nodules and
small airway disease may all occur.
Patients with co-existent
pneumoconiosis may produce large Kidney:
cavitating lung nodules (Caplan's Direct renal damage is rare however
syndrome). Bronchiolitis obliterans most of the drugs used in the treatment
with organizing pneumonia (BOOP) of rheumatoid arthritis can cause renal
is rare. disease.

Skin: Haematology:
Rheumatoid nodules are found in 20% Splenomegaly and neutropenia in
of patients. They consist of a central rheumatoid arthritis is termed Felty's
necrotic core surrounded by a layer of syndrome. Anaemia may occur due to
fibroblasts with an outer coat of chronic disease iron deficiency, or
lymphocytes. Nodules commonly rarely haemolysis.
occur at pressure points but may form
on any internal or external surface.
Raynaud's phenomenon is common.

Figure 8.1 Extra-articular features of rheumatoid arthritis.

but because of side effects, doses should be gradually Tumour necrosis factor alpha (TNF-α) inhibitors
reduced and stopped if possible once the disease is (etanercept and infliximab) are used in patients with
quiescent. persistently active rheumatoid arthritis that has not
Disease modifying antirheumatic drugs: Patients with responded adequately to at least two DMARDs, in-

rheumatoid arthritis should be treated with DMARDs cluding methotrexate.
soon after diagnosis, as these have been shown to im- Anti-cytokines including anti-IL-1 and anti-IL-6 are
proveprognosis.Theyacttoamelioratesymptomsand undergoing evaluation.
slow progression of structural damage. Methotrex- Because of immobility and steroid therapy patients
ate is normally used as first line, other agents include with rheumatoid arthritis are at high risk for develop-
sulphasalazine, gold and hydroxychloroquine. Com- ment of osteoporosis. Most patients should be treated
binations of DMARDs are increasingly used. Onset with calcium and vitamin D supplementation. Bis-
is slow, 10–20 weeks, and all have some degree of phosphonate therapy should be considered in high-
toxicity. risk patients.