Amyloidosis

Amyloidosis may be found in 20Ð60% of rheumatoid cases at autopsy, but it is not commonly evident in living patients [91, 92]. The main indicator is proteinuria due to the deposition of amyloid in the glomerulus. Other possible involved organs are the heart, liver, spleen, intestinal wall, and skin. Diagnosis is conÞrmed by Congo red staining on involved tissue (skin, rectal, and gingival tissues) [93, 94]. Effective suppression of RA is the treatment of choice [95].

Miscellaneous

SpeciÞc hepatic lesions are uncommon in the early course of RA, although liver function tests yield mildly elevated results in almost half the patients; serum alkaline phosphatase, 5¢-nucleotidase, and g-glutamyl transpeptidase are the enzymes usually found to be elevated [96]. g-Glutamyl transpeptidase increases with arthritis activity in a way similar to the CRP. NonspeciÞc hepatomegaly is present in 10Ð20% of patients [97].

Although gastrointestinal involvement is unlikely in uncomplicated RA, infarction, hemorrhage, or perforation of the bowel may occur in rheumatoid vasculitis [98, 99]. Vasculitis also may involve pancreatic or peritoneal vessels. Gastric ulcers are common in patients with RA, but they are mostly caused by nonsteroidal anti-inßammatory drugs used in treating the disease [100].

Direct kidney involvement is rare in RA, but amyloidosis and toxicity from therapy may be indirect causes of renal disease [99Ð103]. Amyloid deposits may lead to renal failure. Drugs that may cause nephritis are phenacetin, salicylates, D-penicillamine, and gold salts [104, 105].

Bone involvement, such as osteoporosis, correlates with the duration of RA, age and sex of the patient, and use of steroids. Osteomalacia also may occur but only ten or more years after the onset of arthritis [106].

6.1.1.3 Ocular Manifestations

Although keratoconjunctivitis sicca (KCS) is the most common ocular manifestation in adult RA, scleritis and peripheral keratitis are the most severe. Other ocular manifestations in RA include episcleritis and ocular motility disturbances.

Some of peripheral keratitis and ocular motility disturbances are caused by contiguous scleritis. Uveitis, glaucoma, and funduscopic changes are rarely seen in RA, except as an extension of scleral inßammation.

Keratoconjunctivitis Sicca

Keratoconjunctivitis sicca or dry eye syndrome appears in 11Ð35% of patients with RA, with women being affected far more often than men (9:1) [107Ð110]. It is bilateral and the onset usually is in the fourth to Þfth decade. KCS results from decreased tear secretion by the main and accessory lacrimal glands. Characteristic complaints are itching, burning, foreign body sensation, and (less often) photophobia, inability to form tears, or excess tearing due to irritation from dryness; the condition occasionally may be asymptomatic [111]. Characteristic signs are slight redness, papillary conjunctivitis, decreased tear breakup time, mucous debris in the conjunctival sac, mucous debris and desquamated epithelial cells attached to the cornea (Þlamentary keratitis), and punctate gray corneal opacities (superÞcial punctate keratitis). SpeciÞc diagnostic tests include 1% rose bengal dye, which attaches to abnormal corneal and conjunctival epithelial cells (Fig. 6.5) (van Bijsterveld scoring system: staining score of 3 or more on a scale from 0 to 3 in each of three zones of the eyeÑ medial, corneal, and lateralÑis considered abnormal), and SchirmerÕs tear test, which quantitates physiologic tear secretion (5 mm or less of Þlter paper wetting in 5 min indicates low tear secretion). Chronic drying may lead to recurrent blepharitis, conjunctivitis, and corneal ulceration. The severity of KCS symptoms correlates with age and duration of RA, but does not correlate with the severity of the arthritis [107]. When dryness of the mouth (xerostomia) is associated with KCS in patients with a connective tissue disease (usually RA), the resultant triad is a multisystem autoimmune disorder known as SjšgrenÕs syndrome [112, 113]. The presence of either xerostomia or KCS with a connective tissue disease is still accepted as sufÞcient.

SjšgrenÕs syndrome occurs more often in patients with rheumatoid scleritis compared with