<prompt> Which of the following is seen in Seropositive Rheumatoid Arthritis?Multiple joints affectedSymmetrical joint symptomsMorning stiffness, joint pain and swellingAll of the above  <response>: D All of the above?Rheumatoid arthritis RA is a chronic inflammatory disease of unknown etiology marked by a symmetric, peripheral polyarthritis.It is the most common form of chronic inflammatory arthritis often results in joint damage and physical disability.Because it is a systemic disease, RA may result in a variety of extraarticular manifestations, including fatigue, subcutaneous nodules, lung involvement, pericarditis, peripheral neuropathy, vasculitis hematologic abnormalities. Rheumatoid Arthritis Criteria 1987 revision, American Rheumatism Association:Morning stiffness inaround joints, 1 hr before maximal improvementArthritis swelling of 3 or more joint areas observed by physicianSymmetric arthritis swelling, NOT bony overgrowthArthritis of Hand joints wrists, MCPs or PIPsRheumatoid nodulesRheumatoid factor serumRadiographic changes erosions andor peri-articular osteopenia in handwrist jointsRequirements: 4 of the above 7 criteria. Criteria 1-4 must have been present for at least 6 weeks.Characteristic hand signs:Z-thumbs, Boutonniere, swan-necking, ulnar deviation, muscle wasting, subluxation of MCP, sometimes Carpal tunnel syndrome, Atlantoaxial subluxationExtra-articular features; Sjogren ds syndrome, Reynauds, vasculitis. Nodules firm but usually painlessPathology: Auto-antibody production 70IgM,30IgG against joint tissues.Investigations:Blood: RA factor positive. Rheumatoid factor is not diagnostic. Present in 70, but also in general population. Rheumatoid positive disease has worse prognosis and more extensive deformity. Anti-CCP antibodies test similar to rheumatoid factor, ESR CRP, normochromic-normocytic anaemia common.X-ray: look for nodules, soft-tissue swelling, osteopaenia, deformity, erosions.Treatment:Aim to reduce long-term deformity LoF. Steroids induce remission, beware SEs long termDMARDs are mainstay. All can cause myelosuppression and rash plus: Sulfasalzine: hepatic impairment, oligospermia, methotrexate; GI disturbance give folic acid to reduce, mouth ulcers, hepatic impairment gold; medical emergency rash, photosensitivity, nephrotic syndrome; leflunomide, chloroquine: retinitis, tinnitus, infliximab; anti TNF- a agent: can cause reactivation of latent diseases e.g. TB. 