HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi
Part 3 of 8 in Diagnosis and Management of Rheumatoid Arthritis
Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
September 1, 2024
Dr. Ajmani was direct on this point: rheumatoid arthritis is a clinical diagnosis. A positive rheumatoid factor does not by itself mean a patient has rheumatoid arthritis, and the two must always be clinically correlated.
Where rheumatoid factor misleads
Rheumatoid factor can also be positive in tuberculosis, infective endocarditis, hepatitis B and C, and even in normal people over the age of 70. Anti-CCP antibody, often treated as more specific, can also be positive in psoriatic arthritis, hepatitis B and C, and tuberculosis. Neither test is diagnostic in isolation.
Joint distribution and imaging as corroborating evidence
Asked why rheumatoid arthritis characteristically involves certain joints and spares others, Dr. Ajmani explained that DIP (distal interphalangeal) joint involvement is less common in RA because there is less synovium in the DIP joints compared to the more commonly affected proximal and metacarpophalangeal joints. Newer imaging tools help confirm the clinical picture: ultrasonography can detect synovial thickening and, on Doppler, increased vascularity, picking up early synovial disease that can complement X-ray findings, particularly useful since plain X-ray changes typically only appear late.
This article is based on a Jivo Masterclass session conducted by Dr. Sajal Ajmani, HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a rheumatology consultation or a second opinion? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass: Dr. Sajal Ajmani taught doctors across Africa on September 1, 2024.
FROM THE LIVE Q&A
Dr. Bafomba
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?
Dr. Sajal Ajmani
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Frequently Asked Questions
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?▼
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
What is the recommended medical treatment for palindromic rheumatism?▼
Hydroxychloroquine.
What is the definition of sustained remission?▼
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?▼
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?▼
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Can rheumatoid factor be positive without RA?▼
Yes. RF can be positive in tuberculosis, infective endocarditis, hepatitis B and C, and in normal people over 70. Anti-CCP can also be positive in psoriatic arthritis, hepatitis B/C and tuberculosis.
Why does RA typically spare the DIP joints?▼
Because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
In This Series: Diagnosis and Management of Rheumatoid Arthritis
- 1.Diagnosis and Management of Rheumatoid Arthritis
- 2.Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
- 3.Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
- 4.Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
- 5.Monitoring Disease Activity: DAS28, SDAI, CDAI and the ACR Response Criteria
- 6.Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
- 7.Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
- 8.Extra-Articular Rheumatoid Arthritis: Lung, Eye, Heart, Kidney and Skin Involvement