Dr. Norman B. Gaylis

In my several years as a practicing rheumatologist, I have noticed that many people with arthritis -and sometimes, their doctors -harbor the mistaken notion that arthritis confines its symptoms to the joints alone. Certainly, the most common arthritic disorders relate to pain and swelling of the joints, but in many instances, this is just the tip of the iceberg. Extra-articular (outside the joint) manifestations of rheumatoid arthritis can, in some cases, cause extreme discomfort.

Actually, the term ‘rheumatoid arthritis’ is a misnomer. The condition should be called rheumatoid disease because of the wide range of symptoms and findings that can appear, without any apparent, direct relationship to the joints themselves. Obviously, this is because rheumatoid arthritis is not a joint disease, but is rather a generalized, inflammatory disease of the immune system, and thus can affect just about any organ system. In my view, a thorough knowledge of potential problems, no matter how rare, through consultation with a rheumatologist, will ultimately promote better health and reduced medical bills for the person with R.A.-and hopefully will not cause undue worry at every twinge or cough.

Most of the extra-articular manifestations of rheumatoid arthritis can be ascribed to either vasculitis, rheumatoid nodules, or serositis.

In vasculitis, which is an inflammation of the small blood vessels, findings may vary from skin ulceration (the

death of skin cells caused by the lack of blood flow) to inflammation of the nerve endings, which may cause weakness or abnormal sensations in the fingers and toes ranging from a pins-andneedles feeling to total numbness. In very severe cases, bleeding from the gastrointestinal tract and even stroke can result. It is important to recognize these symptoms in a very early state, because appropriate treatment can correct and very often reverse the problem.

Large rheumatoid nodules-hard clumps of tissue-are often seen on pressure points such as the elbows. While they are usually asymptomatic, though detectable, they may become painful and if the skin breaks down, or ulcerates, there rises the possibility of a secondary infection. Nodules are particularly uncomfortable when they appear over pressure points such as the buttocks.

The most serious extra-articular manifestation of R.A., however, is serositis -either pleuritis (an inflammation of the lining of the lungs) or pericarditis (an inflammation of membranes which cover the heart). The latter may result in the person having severe chest pain, fever and coughing. With the former, the clinical picture is very similar to that of pneumonia: fluid build-up, fever, coughing and, at times, the coughing up of blood.

Other manifestations of R.A. include anemia, enlargement of the lymph nodes (especially around an inflamed joint), inflammation of the eye, and, due to involvement of the joints of the larynx, hoarse voice, pain on swallowing, and shortness of breath.

Finally, in people whose rheumatoid arthritis has affected the cervical spine, neurological manifestations must he considered. Cervical spine involvement can cause severe pain in the neck and head, and weakness in the arms and legs. People with R.A. should take particular care in looking after the neck, preventing any form of trauma or whiplash injury. Many physicians advise such people to wear a cervical collar. Surgical stabilization of the spine is employed only on those rare occasions when, due to spinal cord compression, severe and definite neurological signs appear.

Fever, weakness in the extremities, chest pain-quite a catalog of symptoms. But keep in mind that such problems can also stem from everyday disorders such as a common virus, totally unrelated to your arthritis. Therefore it is very important to keep your rheumatologist informed of any change in your symptoms to help distinguish your arthritis symptoms from any other problems. For the most part, these problems are treatable, and even reversible.