Articular Attack
Like a toy in the attic, collecting dust until polished and thrown back into the mainstream of the temple’s hallowed halls, rheumatoid arthritis (RA) subtracts luster and adds exquisite pain to muscles and joints long ignored in a restful and tranquil hibernation. Dormancy breeds contentment, especially in the fairer sex, until some as yet unknown trigger unleashes a symmetric articular maelstrom that rivals a perfect storm and leaves its hapless wayfarers cursing the day they were born. In short, RA is no fun, and its countless victims, currently estimated at 0.8% of the U.S. population with three times more women than men suffering its ravages, to second that attestation. Most cases, 80% in fact, develop between the ages of 35 and 50 years of age, with the onslaught attributed to a possible infectious agent such as the measles virus or the virus causing infectious mononucleosis. Whoever or whatever the culprit initiating the skirmish, the ebb and flow of battle results in devastation of joint linings and their associated blood vessels, along with an unhealthy dose of inflammatory cell invasion and edema. The latter cells release a barrage of activated substances and destructive enzymes that are up to no good, degrading the joints even further. If that were not enough, reserves are called up from the rear to discharge a battery of antibodies, which attack self-proteins called antigens that have no other fault than being in the right articular zone of combat at the wrong time.
Hostilities begin with vague symptoms of fatigue, loss of appetite, and muscle, bone, and joint pain, that gradually progress over the course of weeks or months to a more specific chain of cataclysmic events. Several joints, especially those of the hands, wrists, knees, and feet become involved symmetrically, with no prisoners taken in that 10% of the combatants who wage an acute and losing battle against fever, enlarged lymph nodes, and a spleen that roars its resentment to its increased girth. Pain in affected joints, aggravated by movement, is the alarm sounded and call to arms, with morning stiffness of greater than an hour duration interdicting immediate obedience to the bugle’s blare. Inflamed joints are held in a flexed posture, resembling a “Z,” the neck of a swan, or a buttonhole, in order to maximize their volumes and consequently minimize the hurt. Laboratory surveillance, counterintelligence, and a sending in of skirmishers to scout the terrain and lay of the land do little to extend the beachhead, as 5% of healthy recruits demonstrate rheumatoid factor, an autoantibody whose presence is not necessarily specific enough to warrant capitulation. In fact, RA may be mimicked or camouflaged by any number of conditions harboring rheumatoid factor; those being lupus, hepatitis B, tuberculosis, leprosy, syphilis, chronic liver disease, malaria, infectious mononucleosis, bacterial endocarditis, and a host of others all to ready to swing into action.
So, what to do? What weaponry in the possession of a modern-day bombardier or rheumatologist can slow the progression of disease, while at the same time lessening its cost in blood and treasure? Obviously, exercise directed at maintaining muscle strength and joint mobility is the first line of defense and stopgap measure to halt RA invasion. When lines are overrun, bigger guns are called to bear on troop movements of autoantibodies that if left to rape, pillage, plunder, and otherwise wreak havoc on the articular landscape, will inevitably result in disabilities so grave as to compromise daily activities and quality of life. Enter the fray, low-dose anti-inflammatory steroids, and, if need be, disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and sulfasalazine, to temper RA destructive capacity. Symptom mitigation and pain relief via nonsteroidal anti-inflammatory drugs (NSAIDs), simple analgesics, and cycloogenase (COX) inhibitors (or Coxibs) may additionally be drafted into service. Finally, when all else fails, a resort to nukes, in the form of potent biologics, is authorized to control signs and symptoms of RA, slow damage to joints, and limit disability, all at the expense of a crippled defense budget.
Make no bones about it. When the dogs of war are unleashed by RA on unsuspecting joints, their bites are inevitable, at the cost of sometimes muted barks.
ã 2011, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
2/02/2011 06:27:00 AM
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