Clinical Immunology focuses on the immune system’s health. Learn about the diagnosis and treatment of allergies, autoimmune diseases, and immunodeficiencies.
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Diagnosis and Evaluation
Diagnosing rheumatoid arthritis requires a complex integration of clinical observation, laboratory data, and imaging studies. There is no single test that confirms the disease with absolute certainty. Instead, rheumatologists at Liv Hospital use a criteria-based approach to evaluate the probability of the disease. Early diagnosis is the most critical factor in preserving joint function, as the “window of opportunity” for preventing irreversible damage occurs in the early stages of the disease. The evaluation process is continuous, assessing not just the presence of the disease but its activity level and impact on the patient’s life.
Physical Examination and History
Clinical Assessment
The doctor performs a thorough joint count, checking for swelling, tenderness, and warmth. The number and location of swollen joints are heavily weighted in the diagnostic criteria.
Medical History
Detailed history taking focuses on the duration of morning stiffness, the pattern of joint involvement, and family history. The chronicity of symptoms—lasting six weeks or more—is a key diagnostic threshold.
Serological Testing (Blood Work)
Rheumatoid Factor (RF)
This is an antibody found in about 80% of people with rheumatoid arthritis. However, it can also be present in other conditions or healthy individuals, so it is not definitive on its own.
Anti-CCP Antibody
The test for anti-cyclic citrullinated peptide (anti-CCP) is more specific than RF. A positive result for anti-CCP is a very strong indicator of rheumatoid arthritis and often predicts a more aggressive disease course.
ANA Panel
Antinuclear Antibody (ANA) tests may be run to rule out other autoimmune diseases like lupus that can mimic arthritis symptoms.
Inflammatory Markers
Erythrocyte Sedimentation Rate (ESR)
This test measures how fast red blood cells settle at the bottom of a test tube. A faster rate indicates systemic inflammation in the body.
C-Reactive Protein (CRP)
CRP is a protein produced by the liver in response to inflammation. High levels correlate with disease activity and are used both for diagnosis and to monitor how well treatments are working.
Imaging Modalities
X-Ray Evaluation
Traditional X-rays are used to look for joint damage, such as bone erosion or narrowing of the joint space. In the early stages, X-rays may appear normal, but they serve as a baseline for future comparison.
Ultrasound
Musculoskeletal ultrasound is increasingly used to detect synovitis (inflammation of the lining) that is not visible on X-rays. It helps in early diagnosis by visualizing fluid and increased blood flow in the joints.
MRI Scans
Magnetic Resonance Imaging (MRI) provides the most detailed images. It can detect early bone edema (swelling inside the bone) and erosions long before they become visible on standard X-rays.
Scoring Systems and Activity Measures
DAS28 Score
The Disease Activity Score 28 (DAS28) is a standardized tool used to calculate disease activity. It combines the number of swollen and tender joints (out of 28 specifically checked), blood test results (ESR or CRP), and the patient’s own assessment of their health.
Clinical Significance
This score categorizes the patient’s state into remission, low, moderate, or high disease activity, which directly guides treatment decisions in a “treat-to-target” strategy.
Differential Diagnosis
Ruling Out Mimics
The evaluation must distinguish rheumatoid arthritis from other conditions. Osteoarthritis, gout, psoriatic arthritis, and viral arthritis (like Parvovirus B19) can present with similar symptoms.
Arthrocentesis
In cases where the diagnosis is unclear or gout is suspected, fluid may be aspirated from a swollen joint using a needle. The fluid is analyzed for crystals (indicating gout) or white blood cell counts (indicating infection or inflammation).
Functional Assessment
HAQ-DI
The Health Assessment Questionnaire Disability Index (HAQ-DI) measures the patient’s physical function. It assesses the ability to perform daily tasks like dressing, eating, and walking.
Impact Evaluation
Understanding the functional impact is part of the diagnosis. It helps the medical team understand the severity of the disability and the need for occupational therapy or assistive devices.
Comorbidity Screening
Cardiovascular Risk Assessment
Because of the link to heart disease, evaluation includes checking blood pressure, cholesterol, and diabetes risk factors.
Bone Density Scan (DEXA)
Chronic inflammation and steroid use can weaken bones. A bone density scan checks for osteoporosis, which is a common comorbidity that must be managed alongside the arthritis.
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FREQUENTLY ASKED QUESTIONS
Why did my doctor order so many different blood tests?
No single test confirms rheumatoid arthritis. Doctors need a combination of tests for antibodies (RF, Anti-CCP) and inflammation (ESR, CRP) to build a complete picture of your immune system’s activity.
Can I have rheumatoid arthritis if my blood tests are normal?
Yes, this is called “seronegative” rheumatoid arthritis. You can have the symptoms and joint damage without the antibodies being present in your blood.
What is the purpose of an ultrasound in diagnosis?
Ultrasounds are more sensitive than X-rays for detecting early inflammation and fluid in the joints. They can find problems before permanent bone damage occurs.
What is a DAS28 score?
It is a calculation used to measure how active your disease is. It helps your doctor decide if your current treatment is working or if it needs to be changed.
Why do I need a chest X-ray?
Since rheumatoid arthritis can affect the lungs, a chest X-ray checks for any lung inflammation or scarring that might be related to the disease or its treatments.
