Term
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Definition
• Chronic multisystemic disease of an unknown cause.
• The characteristic feature: persistent inflammatory synovitis with cartilage destruction and bone erosion
• Usually involving peripheral joints in a symmetric distribution.
• The course of disease: variable from mild disease to progressive polyarthritis with marked joint deformity. |
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Term
| rheumatoid arthritis Epidemiology |
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Definition
• Prevalence:
1) 1% of general population.
2) increases with age
• M:F=1:3. Sex difference diminishes in older age groups.
• 80% of patients develop the disease between the ages of 35 and 50. |
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Term
| Rheumatoid arthritis Etiology |
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Definition
• Genetics
• Break down of self-tolerance
• Infections, smoking |
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Term
| Genetics of Rheumatoid Arthritis |
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Definition
• Familial history: About 10% of RA patients have an affected first-degree relative.
• Monozygotic twin concordance rate: 34% and dizygotic twin concordance rate 3%.
• MHC II association. |
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Term
| Breakdown of self-tolerance in rheumatoid arthritis |
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Definition
| • leading to reactivity to self-antigens in the joints such as type II collagens, or loss of immunoregulatory control mechanisms resulting in polyclonal T cell activation |
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Term
| Pathogenesis of rheumatoid arthritis |
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Definition
[image]
So this next cartoon here is a depiction of the longitudinal course of RA. So you see on the top there are several factors that contribute to the development of pathogenesis of RA, which include the environmental factors we talked about-- smoking, microorganisms. There's a genetic relation to the HLA-DR4 alleles as well as other genes, particularly CTLA-4 and others.
So what happens is several genes and environmental factors combine to cause RA. In genetically-susceptible individuals, environmental factors activate pathogenic autoimmune reactions in the pre-articular phase or lymphoid aspect of the disease. Now, during this part of the disease, you'll develop CCP-specific antibodies and rheumatoid factor, which we'll talk about. But this part of the phase is typically asymptomatic and not a lot of joint pain or joint involvement.
Then we know that there's a transition phase to the articular phase of the disease. The transition is ill-defined. We don't know what causes it. But it may be inspired by processes such as trauma, infection, or perhaps even microbial insults.
As we transition to the articular phase, we then develop articular pain, joint pain, but also other systemic signs and complications of a chronic inflammatory state. That includes cardiovascular disease. We know RA patients and psoriatic patients have a higher degree of cardiovascular disease, so they need to be screened. That includes osteoporosis. So these patients will need to be on calcium, vitamin D, and appropriately screened with DEXA scans. |
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Term
| primary site of pathology in rheumatoid arthritis |
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Definition
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Term
| Initial pathologic event in rheumatoid arthritis steps |
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Definition
1) activation and/or injury of synovial microvascular endothelial cells
This leads to:
- swelling of endothelial cells
- Occlusion of blood vessels with platelets, leukocytes, and fibrin thrombi)
2) increase in the number of synovial lining cells with perivascular mononuclear cell infiltration. |
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Term
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Definition
1)Synovium becomes massively hypertrophic and edematous, and innumerable villous projections of synovial tissue protrude into the joint cavity.
2) Thickened synovium: composed predominantly of macrophage-like cells and smaller numbers of proliferating fibroblast-like synoviocytes. |
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Term
| Panus formation in synovial stromal tissue steps in RA |
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Definition
1) Panus : Massive tumor-like expansion of synovium, consisted of highly invasive and activated fibroblast-like cells and new blood vessels.
2) Panus invades and destroys periarticular bone and cartilage at the margins of joints where synovium and bone are attached (erosion of bare area). |
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Term
| As the disease progresses in RA |
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Definition
erosion Develop and joint capsule becomes distended.
• Deformity |
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Term
| Clinical Manifestations of RA |
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Definition
• Articular manifestations
• Extraarticular manifestations
• Constitutional manifestations |
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Term
| Articular manifestations of RA |
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Definition
• Chronic polyarticular symmetrical inflammatory arthritis
• Pain, swelling, and tenderness of the joints often associated with warmth. Erythema is infrequent.
• Morning stiffness > 1 hour: indicates inflammatory arthritis but not specific
• Most often causes symmetric arthritis with characteristic involvement of wrist, PIP and MCP joints. DIP joints are rarely involved.
• Other appendicular joints can be involved.
• Axial involvement is usually limited to upper cervical spine. |
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Term
| RA vs OA joint involvement |
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Definition
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Term
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Definition
So here are some examples of patients with rheumatoid arthritis. So what you notice here in this image is a fusiform swelling of the proximal interphalangeal joint. You can see this is in the fourth and fifth fingers, but the first and second fingers are spared.
Now very often, since this is a symmetric arthritis, you'll see that the patient's other hand will also have fourth and fifth PIP involvement. It's really quite remarkable. But again, that's not the hard and fast rule. But these are clues that help you distinguish what type of inflammatory arthritis you're dealing with or if this is a non-inflammatory arthritis, such as OA. |
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Term
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Definition
In this image, this is an image-- you're seeing a few different things. You can see some swelling on the dorsum of the hand. But I think the mainstay of this point is this swan neck deformity we're seeing in the middle figure. The swan neck deformity is a bending or flexion of the base of the finger, a straightening out or hyperextension of the PIP joint, and a bending or hyperflexion of the DIP joint. And you can see that hyperflexion is causing the finger to bend like a swan.
So this is the result of an overstretched volar plate due to chronic inflammation of the PIP joint in RA. As a volar plate becomes weakened and stretched, the PIP joint becomes loose and begins to easily bend back into hyperextension. And that's what you're seeing here.
The extensor tendon gets out of balance, which allows the DIP joint to get pulled downward into flexion. As the DIP joint flexes and the PIP hyperextends, the swan neck deformity occurs. And there's not many things that cause swan neck. So if you do see a patient with swan neck, you would want to consider rheumatoid arthritis to be high in your differential. |
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Term
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Definition
Here's another image depicting a few different things. So the first thing we see is what's known as the hitchhiker's thumb, which is a hyperextension of the thumb, which causes an inability to pinch, which obviously reduces your functional capacity. It's quite annoying for people.
Another thing potentially we're seeing here is what's called a floating ulnar head sign. And this is due to destruction of the ulnar collateral ligament. And what happens is the ulnar head, like a piano key, kind of floats to the top of the wrist and you can actually push it down. And when you do, it causes pain. It's quite tender for patients. And that's known as the floating ulnar head sign or the piano key sign.
The next thing you're seeing is prominent MCPs. Now, this may be swelling, but really what it looks like is happening in this picture is subluxation of the proximal phalanx, meaning that it's moving in the palmar direction backwards.
The next thing-- another main point of the slide is a characteristic finding of rheumatoid arthritis, which is the ulnar deviation of the joint where the wrist moves radially. Ulnar deviation is the result of weakening of the extensor carpi ulnaris leading to a radial deviation of the wrist, causing all fingers and tendons to pull ulnarly.
So this can also be seen in lupus, which we'll discuss in one of your later talks. But the important thing is that in lupus this is reversible, whereas in rheumatoid arthritis this is permanent. So obviously you want to treat patients before they get to this point and control their disease. |
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Term
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Definition
| This is what's known as the opera glass hand in rheumatoid arthritis. Apparently the excess skin folds transversely that you see resemble an opera glass and that's why it's referred that way. But really what they're talking about is an arthritis mutilans of the hands, a destructive arthropathy, which leads to the shortening of fingers due to destruction of the phalanges-- opera glass hands. |
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Term
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Definition
| Here's another example of the swan neck deformity of the fourth finger and probably the third finger. But what we're seeing in the fifth finger is another aspect of rheumatoid arthritis known as the Boutonniere deformity. And what we see with Boutonniere deformity of the pinky finger is that the PIP this time is in hyperflexion while the DIP is in hyperextension. Again, this will be seen in patients with rheumatoid arthritis, and not many other disease processes cause this. |
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Term
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Definition
Here's another example of the feet of a patient. And this brings an important aspect of rheumatology. In rheumatoid arthritis, as well as many of our rheumatic diseases, the findings and nuances of the physical exam are very important. You really need to examine your patients in all aspects of joints and all aspects of the body, which includes asking them to remove their feet, remove their socks, which often is overlooked in the clinical setting.
When it's appropriate, you need to evaluate hips and joints without clothing covering them so you can appropriately evaluate the range of motion, swelling, et cetera. So for example, if you didn't take off the socks of a patient, you may not notice and they may not mention that they have what's known as hammer toe from weakening of the ligaments, which causes this claw-like deformity or hammer toe. Patients may not even really report this because hammerer toe they may have for 10, 15 years, it may be unchanging, and they may be living with it and they may think nothing of it. But it's important for you to document and recognize that. |
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Term
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Definition
Here is a good depiction of what happens in rheumatoid arthritis potentially in a hip x-ray. What we're seeing here is a symmetrical loss of joint space, and a narrowing of the joint space, and maybe potentially some subchondral cysts forming. But I think the main point of this slide is that there is the axial or upward migration of the femoral heads due to the destruction of the joint space and loss of cartilage.
It's difficult to make out from this, but there may also be some osteophytes or bony fragments, and it's difficult to evaluate for the presence of erosions based on this image. |
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Term
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Definition
RA on left, OA on right
Now, here's a good slide depicting the difference between rheumatoid arthritis and-- an x-ray in rheumatoid arthritis of the knee, of course, and an x-ray might be seen in osteoarthritis. So what's basically going on here is that you can see rheumatoid arthritis, as we discussed, is a symmetric disease, meaning that both knees are affected. But they're also affected symmetrically. The cartilage is destroyed both medially and laterally-- symmetrically, evenly. And you can see that basically the cartilage is almost gone at certain points and that the bones, the femur and the tibia, are basically almost touching.
Here is a patient on the right having osteoarthritis, and what you notice here is that there's actually decent cartilage on the lateral aspect of the knee where the fibula and the tibia are. You can see that within the space there is good cartilage and that the bones are not touching. But when you explore the medial aspect of the joint, you can see that the cartilage is narrowed, there's asymmetric narrowing of the joint space, and that the bones are almost touching, revealing medial osteoarthritis. |
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Term
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Definition
atlantoaxial subluxation
Here is the atlantoaxial subluxation that we referred to initially, and that's of course of the atlas, C1, and the axis, C2. And what we have is in atlantoaxial instability, basically what it is is characterized by excessive movement at the junction between C1 and C2 as a result of either bony or ligament disabnormality in rheumatoid arthritis. Neurological symptoms can occur when the spinal cord or adjacent nerve roots are affected and cause a variety of symptoms from numbness, tingling, particularly in the arms.
And here is an example of the chord potentially being compressed and the arrows are depicting that. |
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Term
| extra-articular manifestations of rheumatoid arthritis |
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Definition
skin- nodules, fragility, vasculitis, pyoderma gangrenosum
heart- pericarditis, premature atherosclerosis, vasculitis, valvular and valve ring nodules
lung- pleural effusions, interstitial lung disease, bronchiolitis obliterans, rheumatoid nodules, vasculitis
eye- keratoconjunctivitis sicca, episcleritis, scleritis, scleromalacia perforans, peripheral ulcerative keratopathy
neurologic- entrapment neuropathy, cervical myelopathy, mononeuritis multiplex (vasculitis), peripheral neuropathy
hematopoietic- anemia, thrombocytosis, lymphadenopathy, Felty's syndrome
kidney- amyloidosis, vasculitis
bone- osteopenia |
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Term
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Definition
| Here's a depiction of rheumatoid nodules in the skin of a patient-- very clear and kind of obvious to see. Rheumatoid nodules are subcu skin nodules with characteristic histology and the central area of fibrinoid necrosis surrounded by zones of palisading macrophages and lymphocytes. They are typically painless and usually we don't opt for surgical removal because they just grow back. |
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Term
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Definition
• Example of RA being systemic Disease
• Present in 20 to 35% of patients
• Patients with rheumatoid nodules almost always have positive RF.
• Common on pressure points (such as the olecranon process), they form on any surface (inside or outside the body).
• Poor prognosis |
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Term
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Definition
| Here, you see a rheumatoid nodule on the olecranon process and the extensor surface of the elbow. |
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Term
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Definition
Rheumatoid vasculitis: Predominantly seen in patients with severe RA and high titers of RF
So in this image, we're depicting what a potential patient with rheumatoid vasculitis may present as. Again, rheumatoid vasculitis is seen in patients with severe RA, bad RA, and high titers of rheumatoid factor. And you can see some hemorrhaging at the fingertips. |
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Term
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Definition
| Going on again, some examples of rheumatoid vasculitis-- hemorrhaging |
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Term
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Definition
| And on the next cartoon, you see an example of ulceration and digital tip necrosis from really bad rheumatoid vasculitis. Obviously, you're hoping to intervene, treat, and potentially get the patient in a hospitalized setting for appropriate treatment if necessary before this happens because the next step after this, unfortunately, would be amputation. The finger typically would not recover from this extent of damage. |
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Term
| pulmonary manifestations of rheumatoid arthritis |
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Definition
• Pleural effusion, interstitial lung ds, nodules, bronchiolitis obliterans
• More commonly observed in men.
• Symptomatic pleuritis is rare.
• Pleural effusion: very low levels of glucose in the absence of infection.
• Caplan's syndrome: pneumoconiosis and rheumatoid nodule in the lung |
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Term
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Definition
| But what they will show you on the x-ray are basically these pulmonary nodules, which basically are consistent with Caplan's syndrome-- rheumatoid nodules in the setting of pneumoconiosis. |
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Term
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Definition
| RA interstitial lung ds: usually similar to idiopathic pulmonary fibrosis (IPF, also called cryptogenic fibrosing alveolitis (CFA)) |
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Term
| ocular manifestations of rheumatoid arthritis |
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Definition
• Scleromalacia, episcleritis, scleritis: fewer than 1% of patients
• keratoconjunctiva sicca (secondary Sjogren's syndrome): 15 to 20%. |
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Term
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Definition
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Term
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Definition
episcleritis in ra
Here you see a patient with rheumatoid arthritis having episcleritis. You would refer the patient to an ophthalmologist and they would either prescribe topical steroid drops for the eye or, if bad enough, would have oral systemic prednisone therapy, among other biologic options that the ophthalmologist may use as eye drops. |
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Term
| neurologic manifestations of rheumatoid arthritis |
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Definition
• atlantoaxial subluxation,
• Midcervical spine subluxation
• Entrapment syndrome such as carpal tunnel syndrome
• Mononeuritis multiplex secondary to vasculitis |
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Term
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Definition
| Here, this is most likely a cadaveric representation of atlantoaxial subluxation. And what you're seeing here is the spinal cord being compressed-- and you can see the lesion quite clearly here-- from atlantoaxial subluxation. Obviously you want to intervene in the patient before we get to this point. And this would be important in a patient going for elective surgery, again, who might be intubated to get the x-ray of the cervical spine in flexion and extension views to make sure that this complication does not accidentally happen as a cycle of the intubation. |
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Term
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Definition
typically where the median nerve lies in the carpal tunnel. And kind of a trick you could use is when you pinch the thumb and the pinky finger together, the palm forms a crease. Usually that line that the crease forms is along where the median nerve will run. Again, this is just kind of a trick. It's not a hard and fast rule.
We know that Tinel's sign, tapping on the median nerve, produces paresthesias along the shaded area, the shaded area being the first, second, and third fingers, and really half of the fourth finger. But a lot of times patients aren't going to tell you half of the fourth finger, but they'll be able to notice first, second, and third fingers.
Now, treatment for carpal tunnel syndrome can be multi-factorial. You can provide splinting, particularly at night when patients sleep because you don't move your wrist in your sleep then. Physical therapy is helpful. And of course, we can give corticosteroid injections as long as the risks are explained to the patient and as long as you're not doing it too often because steroids have their own side effects. |
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Term
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Definition
• No tests are specific for diagnosing RA
• RF: About 85% of RA patients have
• Anti-CCP Abs (ACPA)
• Increased ESR: typically correlates with the degree of synovial inflammation
• Increased CRP: Elevation of both ESR and CRP together are stronger indications of radiologic progression than CRP alone
• Hypergammaglobulinemia
• Anemia
• Thrombocytosis |
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Term
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Definition
• RF is not specific for RA. • Not a screening test
• Can be used to confirm diagnosis in patients with a suggestive clinical presentation.
• About 15% of RA patients do not have RF. |
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Term
| Other conditions with positive RF |
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Definition
• Other conditions with positive RF:
1) SLE, Sjogren's, chronic liver diseases (viral hepatitis B and C), sarcoidosis, interstitial pulmonary fibrosis, infectious mononucleosis, TB, leprosy, syphilis, SBE, and malaria.
2) Transiently after vaccination. 3) Relatives of RA patients. |
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Term
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Definition
1) Patient with high titers tends to have more severe and progressive disease.
2) Correlates with extraskeletal manifestations (nodules). Patient with RA vasculitis has very high titer.
3) Fluctuation of titers in individual patients does not correlate with disease activity. |
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Term
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Definition
• Values
1. Differential Dx of early RA from other ds such as lupus and Sjogren’s
2. Predicting joint damage
3. Predicting joint damage in patients with negative RF
So the anti-CCP antibody is also helpful, particularly to differentiate RA from other diseases such as lupus and Sjogren's because, like we said, RF can be positive in lupus and Sjogren's. A lot of symptoms can overlap, particularly arthralgias.
CCP antibody can be predictive of joint damage. So if you have a high CCP, you want to screen with x-rays and potentially escalate therapy before erosions occur. And also, it's good at predicting joint damage in the future for patients who actually have negative rheumatoid factor. So it could be good for monitoring these patients. |
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Term
| Sensitivity and Specificity of anti-ccp, IgM RF, IgM RF and anti-CCP |
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Definition
• Anti-CCP — sensitivity 56 percent, specificity 90 percent
• IgM RF — sensitivity 73 and specificity 82 percent
• IgM RF and anti-CCP — sensitivity 48 and specificity 96 percent |
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Term
| Hematologic findings in RA |
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Definition
• Anemia of chronic disease: Normochromic normocytic anemia. Low serum Iron, TIBC, and high ferritin.
• Thrombocytosis (acute phase reactant) correlates with disease activity.
• Eosinophilia: reflects severe systemic disease.
• Leukopenia.
a. Felty’s: RA, splenomegaly, and leukopenia. Most common in individuals with long-standing RA. |
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Term
| Synovial fluid analysis in RA |
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Definition
| • Inflammatory fluid: WBC > 2,000, often greater than 10,000 |
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Term
| Radiological evaluation in RA |
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Definition
• Early disease: soft tissue swelling and joint effusion, usually symmetrical pattern.
• Several weeks after the onset of RA: Juxtaarticular osteopenia.
• Several months later: Loss of articular cartilage and bone erosions. |
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Term
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Definition
In this example, you're going to see soft tissue swelling, which we can see in rheumatoid arthritis, which can be depicted in kind of this area right here. There are no erosions, but you can see the early joint space narrowing between the joints. Now, this is not a great x-ray for that. But the point of this x-ray is to more identify that some of the early findings are soft tissue swelling.
So when evaluating the x-rays of a patient with rheumatoid arthritis, it's important to remember the earliest areas of erosions can be seen on the radial aspect of the metacarpal head, the thumb radial aspect, the base of the proximal phalanx, the ulnar styloid process, and the pisiform and the triquetrum of the wrist.
So again, get x-rays of a patient with RA, of hands, wrists, and feet, as well as other joints that are affected, but particularly hands, wrists, and feet can reveal a lot about their disease. |
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Term
| • The earliest areas of erosions radiological evaluation in RA |
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Definition
1) radial aspect of metacarpal head 2) base of proximal phalanx
3) ulnar styloid process
4) pisiform and triquetrum. |
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Term
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Definition
| Here, you see, as we talked about, evidence of what is a erosion of the ulnar styloid process. You see the radius here. You see the ulna here. And you can see-- I mean, it's quite subtle in the picture on the left-- just a little bit of an erosion right there. But in the zoomed-in view, you can very clearly see that there is a punched out or kind of erosive lesion here. |
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Term
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Definition
In this image, also depicting the development of an erosion. Perhaps in image A you're seeing an early formation of an erosion or a subchondral cyst. But you can see there's some process going on.
As you move on to B, you can see that this erosion is kind of carving out and developing. And then by the time we get to C, the erosion is fully developed. At this point, we're too late. We cannot do any therapies that will cause the bone to regrow or to reform. But we can only jump on board with therapy to prevent this erosion from becoming worse.
So really, you want to get involved at A or maybe even B. But by the time we get to C, we're a little too late. So at that point, you want to prevent any further damage. |
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Term
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Definition
This is an excellent example of the periarticular osteopenia, the next to the joint bony washout that you can see, the darkening next to the MCP joint here and the PIP joint here. This is also an example of the ulnar deviation, the moving towards the ulnar direction of the fingers of the phalanx.
And finally, you can also see subluxation of the metacarpal phalangeal, the phalanx moving backwards towards the direction of the palm. That's known as MCP subluxation. |
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Term
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Definition
| On this image depicting the bone scan of a patient with rheumatoid arthritis, what we're seeing is enhanced signal activity in the areas of the wrist, the areas of the MCP, and the areas of the PIP. You can see that the DIPs are not affected, and we talked about this as not typically finding rheumatoid arthritis. |
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Term
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Definition
| This is an MRI of the wrist of a patient with rheumatoid arthritis. And what the cartoon is depicting here is frank synovitis or synovial proliferation in the TFCC region of the wrist. |
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Term
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Definition
• Based on typical picture of bilateral symmetric inflammatory polyarthritis involving small and large joints in both upper and lower extremities
• Constitutional symptoms includ morning stiffness, fatigue, weight loss
* positive RF and anti-CCP Abs support diagnosis.
• The diagnosis is somewhat more difficult early in the course when the symptoms are not typical for RA. |
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Term
| 2010 american college of rheumatology criteria for RA |
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Definition
get points for number of joints involved, more pts if high-pos RF or high pos ACPA, 1 pt if abnormal CRP or abnormal ESR, duration of symptoms >/= 6 weeks, RA is score of >/= 6/10
-these criteria were developed for epidemiological studies |
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Term
| keys to optimize outcome of RA treatment |
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Definition
| early accurate diagnosis, early DMARD therapy, strive for remission in all pts, monitor carefully for treatment toxicities, consider and treat comorbid conditions |
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Term
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Definition
• None of therapies are curative.
• Needs interdisciplinary approach: (1) Rest
(2) Splinting to reduce unwanted motion of inflamed joints.
(3) Exercise to maintain muscle strength and joint mobility without exacerbation of joint inflammation.
(4) Medical management |
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Term
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Definition
• No known cure or means of prevention • Optimal management
1) Early diagnosis
2) timely introduction of agents to reduce the probability of irreversible joint damage
3) Periodic assessment of disease activity, drug toxicity, and the effectiveness of the treatment |
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Term
| Reasons for early aggressive treatment in RA |
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Definition
• Patients with active, polyaricular, RF+, RA: > 70% probability of developing joint damage or erosions within 2 years of the onset of disease.
• Early aggressive treatment may alter the disease course
• Most rheumatologists favor aggressive treatment early in the course of the disease |
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Term
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Definition
• No significant differences in efficacy among NSAIDs including selective COX II inhibitors
• Differences in individual response to a NSAID may exist: try several NSAIDs
• Low dose: Fewer GI side effects • To reduce GI side effects:
1) take NSAIDs with meal
2) PPI for high risk group |
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Term
| glucocorticoid guidelines |
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Definition
| avoid use of glucocorticoids w/o DMARDs, prednisone >10mg/day rarely indicated for articular disease, taper to the lowest effective dose, use as "bridge therapy" until DMARD therapy effective, remember prophylaxis against osteoporosis. DMARD = disease-modifying antirheumatic drug |
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Term
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Definition
1) Hydroxychloroquine 2) Sulfasalazine
3) Methotrexate
4) Leflunomide
Disease modifying anti- rheumatic
drugs (DMARDs)
5) TNF-α inhibitors: etanercept, infliximab, adalimumab, golimumab
6) Anti-B cell treatment: rituximab (anti-CD20 Abs)
7) IL-1 inhibitor: anakinra
8) IL-6 receptor antibody: tocilizumab
8) CTLA-4-Ig (Fc portion of IgG): Abatacept (Orencia), selective co-stimulation modulator
9) Tofacitinib: oral Janus kinase (JAK) inhibitor 9) azathioprine
10) Gold
11) Cyclosporine |
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Term
| drugs that can cause symptoms of myelosuppression |
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Definition
| sulfasalazine, methotrexate, Gold, D-penicillamine, Azathioprine, Cyclophosphamide, Chlorambucil |
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Term
| drugs that cause cause TB reactivation |
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Definition
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Term
| Clinical course and prognosis in RA |
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Definition
• Quite variable and difficult to predict in individual patients.
• Most patients experience persistent but fluctuating disease activity with variable degree of disability or deformity.
continued
• The greatest progression of disease takes place during the first 6 years.
• Joint damage is greater during the first year than the 2nd or 3rd years of the disease.
• Median life expectancy is shortened by 3 to 7 years.
• 2.5-fold increase in mortality rate largely due to infection and GI bleeding. |
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Term
| Features associated with more severe disease in RA |
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Definition
1) High titers of RF and ACPA 2) SQ nodules
3) HLA-DR4 haplotype
4) Anti-CCP Ab
5) Higher acute phase reactants |
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