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Clinical Summary

Rheumatoid arthritis (RA) is a peripheral, symmetric, and inflammatory polyarthritis. Most manifestations of RA are subacute in nature, including gradual onset of morning stiffness, excessive fatigue, and synovitis in various joint areas, most commonly the wrists, metacarpophalangeal, interphalangeal, and shoulder joints, knees, and neck. There are, however, acute and a rapidly worsening manifestations of RA that can be life threatening. Several different extra-articular manifestations can be seen such as pericarditis, myocarditis, interstitial lung disease, or rheumatoid vasculitis.

In addition, there are a variety of important complications of medications used for the treatment of RA that may present as a true emergency. These include infusion reactions, serum sickness, and infectious complications due to the medications’ immunosuppressive properties.

Importantly, an acute flare of mono- or oligoarthritis in the RA patient should not be automatically attributed to the underlying disease. Patients with RA are at a significantly increased risk for septic arthritis. Therefore, emergency physicians should have a very low threshold of performing an arthrocentesis with a cell count, Gram stain, and cultures in the patient with RA who presents with an acute arthritic flare in a single joint.

Patients with RA have an increased risk of premature death. This is largely due to an increased incidence of coronary artery disease. The likelihood for a patient with RA to die from coronary artery disease is more than 50% higher than in the general population. Therefore, the RA patient presenting with chest pain, shortness of breath, or other symptoms that can occur in the context of coronary artery disease needs to be very carefully evaluated for acute coronary syndrome. Risk of prediction tools such as the HEART score are likely to underestimate the risk of major coronary events in this patient group, since RA is an independent risk factor for arteriosclerosis.

FIGURE 26.20

Rheumatoid Arthritis—Flare. Acute pain, swelling, redness, and morning stiffness of the MCP and PIP joints consistent with rheumatoid arthritis. (Image appears with permission from VisualDx [www.visualdx.com].)

FIGURE 26.21

Rheumatoid Vasculitis. A rare complication of rheumatoid arthritis can manifest as deep ulcers on the legs as a result of medium-sized vessel vasculitis. (Image appears with permission from VisualDx [www.visualdx.com].)

Management and Disposition

Patients with RA disease flares without severe extra-articular manifestations such as a rheumatoid vasculitis, can typically be treated as outpatients with a steroid taper and close rheumatology follow-up. If worsening extra-articular disease is present, patients usually require admission and intravenous (IV) treatment with high-dose steroids.

Emergency providers need to maintain a high index of suspicion for (atypical) infections. Independent of treatment, patients with RA have a higher risk for various infectious diseases. This risk can be further amplified ...

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