Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited (hereditary). It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.
It is not known what triggers the onset of rheumatoid arthritis. Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas.
Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that
smoking tobacco increases the risk of developing rheumatoid arthritis.
What are the symptoms
and signs of rheumatoid arthritis?
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and people generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies among affected individuals, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue,
loss of energy,
lack of appetite, low-grade
fever, muscle and joint aches, and
stiffness. Muscle
and joint stiffness are usually most notable in the morning and after periods
of inactivity. Arthritis is common during disease flares. Also during flares,
joints frequently become red, swollen, painful, and tender. This occurs because the
lining tissue of the joint (synovium) becomes inflamed, resulting in the
production of excessive joint fluid (synovial fluid). The synovium also
thickens with inflammation (synovitis).
Rheumatoid arthritis usually inflames multiple joints in a symmetrical pattern (both sides of the body affected). Early symptoms may be subtle. The small joints of both the hands and wrists are often involved. Symptoms in the hands with rheumatoid arthritis include difficulty with simple tasks of daily living, such as turning door knobs and opening jars. The small joints of the feet are also commonly involved, which can lead to painful walking, especially in the morning after arising from bed. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint
infection. Chronic inflammation can cause damage to body tissues, including cartilage and
bone. This leads to a loss of cartilage and erosion and
weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening
of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of
the voice. Joint symptoms in children with rheumatoid arthritis include limping, irritability, crying, and
poor appetite.
Since rheumatoid arthritis is a systemic disease, its
inflammation can affect organs and areas of the body other than the joints. Inflammation of the
glands of the eyes and mouth can cause dryness of these areas and is referred to
as Sjogren's syndrome. Dryness of
the eyes can lead to corneal abrasion. Inflammation of the white parts of the eyes (the sclerae) is referred to as
scleritis and can be very dangerous to the eye. Rheumatoid inflammation of the lung lining (pleuritis)
causes chest pain with deep breathing, shortness of breath, or
coughing. The lung tissue itself can also become inflamed,
scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the
lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying
down or leaning forward. The rheumatoid disease can reduce the number of red blood cells
(anemia) and white blood cells. Decreased white
cells can be associated with an enlarged spleen (referred to as Felty's
syndrome) and can increase the risk of infections. Firm lumps under the skin
(rheumatoid nodules) can occur around the elbows and fingers where there is
frequent pressure. Even though these nodules usually do not cause symptoms,
occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually
with long-standing rheumatoid disease, is blood vessel inflammation
(vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue
death (necrosis). This is most often initially visible as tiny black areas around the nail
beds or as leg ulcers.
Rheumatoid Arthritis - Early SymptomsQuestion: The symptoms of rheumatoid arthritis (RA) can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Gout is a condition that results from crystals of uric acid depositing in tissues of the body. Gout is a condition that can lead to abnormally elevated levels of uric acid in the
blood, recurring attacks of joint inflammation (arthritis), deposits of
hard lumps of uric acid in and around the joints, and decreased kidney
function and kidney stones.
The knee joint is composed of three compartments and ligaments which stabilize the joint. Causes of knee pain may include injury, degeneration, infrequently infection and rarely bone tumors. Although routine x-rays do not revel meniscus tears, they can be used to exclude other problems of the bones and tissues. The knee joint is the most commonly involved joint in rheumatic disease, as well as immune diseases that affect various tissues of the body.
Lymph nodes help the body's immune system fight infections. Causes of swollen lymph nodes (glands) may include infection (viral, bacterial, fungal, parasites). Symptoms of swollen lymph nodes vary greatly. They can sometimes be tender, painful or disfiguring. The treatment of swollen lymph nodes depends upon the cause.
Sjögren's syndrome is an autoimmune disease involving the abnormal production of extra antibodies that attack the glands and connective tissue. Sjögren's syndrome with gland inflammation (resulting dry eyes and mouth, etc.) that is not associated with another connective tissue disease is referred to as primary Sjögren's syndrome. Sjögren's syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjögren's syndrome. Though there is no cure for Sjögren's syndrome, the symptoms may be treated by using lubricating eye ointments, drinking plenty of water, humidifying the air, and using glycerin swabs. Medications are also available to treat dry eye and dry mouth.
Lyme disease is a bacterial illness, which is spread by ticks when they bite the skin. Initially the disease affects the skin causing a reddish rash associated with flu-like symptoms. It takes weeks to months after the initial redness of the skin for its effects to spread throughout the body. Lyme disease can be treated with antibiotics. Lyme disease can be prevented by using tick avoidance techniques.
Systemic lupus erythematosus is a condition characterized by chronic inflammation of body tissues caused by autoimmune disease. Lupus can cause disease of the skin, heart, lungs, kidneys, joints, and nervous
system. When only the skin is involved, the condition is called discoid lupus.
When internal organs are involved, the condition is called systemic lupus
erythematosus (SLE).
Ankle pain is commonly due to a sprain or tendinitis. The severity of ankle sprains ranges from mild (which can resolve within 24 hours) to severe (which can require surgical repair). Tendinitis of the ankle can be caused by trauma or inflammation.
Sacroiliac joint (SI) dysfunction is a general term to reflect pain in the SI joints. Causes of SI joint pain include osteoarthritis, abnormal walking pattern, and disorders that can cause SI joint inflammation including gout, rheumatoid arthritis, psoriasis, and ankylosing spondylitis. Treatment includes oral medications, cortisone injections, and surgery.
Arthritis is inflammation of one or more joints. When joints are inflamed they can develop stiffness, warmth, swelling, redness and pain. There are over 100 types of
arthritis including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus, gout,
and pseudogout.
Raynaud's phenomenon is characterized by a pale-blue-red sequence of color changes of the digits, most commonly after exposure to cold. Occurring as a result of spasm of blood vessels, the cause is unknown. Symptoms of Raynaud's phenomenon depend on the severity, frequency, and duration of the blood vessel spasm. Treatments include protection of the digits, medications, and avoiding emotional stresses, smoking, cold temperature, and tools that vibrate the hands.
Celiac disease is a result of an immune reaction to gluten, a protein found in wheat or related grains and present in many foods that we eat. Celiac disease causes impaired absorption and digestion of nutrients through the small intestine. Signs and symptoms of celiac disease include malabsorbption (diarrhea, foul smelling gas, bloating, and increased amounts of fat in the stool) and malnutrition (weight loss, edema, anemia, bruising easily, neuropathy, and infertility). Treatment for celiac disease is a gluten free diet, and at times if necessary, medications
A Baker cyst, also called a popliteal cyst, is swelling caused by knee joint fluid protruding to the back of the knee (popliteal area of the knee). Not uncommon, baker cysts can be caused by virtually any type of joint swelling (arthritis). They are often resolved with removal of excess knee fluid in conjunction with cortisone injections.
Pleurisy, an inflammation of the lining around the lungs, is associated with sharp chest pain upon breathing in. Cough, chest tenderness, and shortness of breath are other symptoms associated with pleurisy. Pleurisy pain can be managed with pain medication and by external splinting of the chest wall.
Bursitis of the knee results when any of the three fluid-filled sacs (bursae) become inflamed due to injury or strain. Symptoms include pain, swelling, warmth, tenderness, and redness. Treatment of knee bursitis depends on whether infection is involved. If the knee bursa is not infected, knee bursitis may be treated with ice compresses, rest, and antiinflammatory and pain medications.
Cushing's syndrome, sometimes referred to as hypercortisolism, is a hormonal disorder caused by prolonged exposure to high levels of the hormone cortisol. Symptoms may include obesity, thinning arms and legs, a rounded face, and increased fat around the neck. Some causes of Cushing's syndrome is from taking glucocorticoid hormones such as prednisone for inflammatory diseases. Treatment for Cushing's syndrome depends on the cause.
Vasculitis is a general term for a group of uncommon diseases which feature inflammation of the blood vessels. Each form of vasculitis has its own characteristic pattern of symptoms. The diagnosis of vasculitis is definitively established after a biopsy of involved tissue demonstrates the pattern of blood vessel inflammation. Treatment is directed toward decreasing the inflammation of the arteries and improving the function of affected organs.
Dry eyes are caused by an imbalance in the tear-flow system of the eye, but also can be caused by the drying out of the tear film. This can be due to dry air created by air conditioning, heat, or other environmental conditions.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
Amyloidosis is a group of diseases resulting from abnormal deposition of certain proteins (amyloids) in various bodily areas. The amyloid proteins may either be deposited in one particular area of the body (localized amyloidosis) or they may be deposited throughout the body (systemic amyloidosis). There are three types of systemic amyloidosis: primary (AL), secondary (AA), and familial (ATTR). Primary amyloidosis is not associated with any other diseases and is considered a disease entity of its own. Secondary amyloidosis occurs as a result of another illness. Familial Mediterranean Fever is a form of familial (inherited) amyloidosis. Amyloidosis treatment involves treating the underlying illness and correcting organ failure.
Connective tissue disease is when the body's connective tissues come under attack, possibly becoming injured by inflammation. Inherited connective tissue diseases include Marfan syndrome and Ehlers-Danlos syndrome. Systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymositis, and dermatomyositis are examples of connective tissue diseases that have no known cause.
Osteopenia is a bone condition characterized by bone loss that is not as severe as in osteoporosis. Bone fracture is the typical symptom of osteopenia, though the condition may be present without symptoms. Treatment involves lifestyle modifications (quitting smoking, not drinking in excess) and ensuring an adequate intake of vitamin D and calcium.
Still's disease (Systemic-Onset Juvenile Rheumatoid Arthritis) is a disorder characterized by inflammation with high fever spikes, fatigue, salmon-colored rash and/or arthritis. Though there have been several theories regarding the cause(s) of Still's disease, the cause is not yet known. Many symptoms of Still's disease are often treatable with anti-inflammatory drugs.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Chronic pain is pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain persists over time and is often resistant to medical treatments.
Juvenile arthritis (juvenile rheumatoid arthritis or JRA) annually affects one child in every thousand. There are three types of JRA: pauciarticular (less than four joints affected), polyarticular (more than four joints affected), and systemic-onset (inflamed joints with high fevers and rash). Treatment of juvenile arthritis depends upon the type the child has and should focus on treating the symptoms that manifest.
A ganglion is a fluid-filled cyst that forms from the joint or tendon lining. Ganglia are most frequently found in the ankles and wrists and are usually painless. A ganglion often resolves on its own. Aspiration of the ganglion fluid or surgery may be necessary.
Relapsing polychondritis is an uncommon, chronic disorder of the cartilage that is characterized by recurrent episodes of inflammation of the cartilage of various tissues of the body. Tissues containing cartilage that can become inflamed include the ears, nose, joints, spine, and windpipe (trachea). Tissues that have a biochemical makeup similar to that of cartilage such as the eyes, heart, and blood vessels, can also be affected. Nonsteroidal antiinflammatory medications (NSAIDs) is used as treatment for mild cases of the disease. Steroid-related medications also are usually required.
Biologic rhythms, or biorhythms, are how our bodies respond to the regular phases of the sun, moon, and seasons. A medical chronobiologist studies how the "body clock" or biorhythms affect diseases and how the body clock responds to treatment of diseases and conditions at different times of the day.
Felty's syndrome is a complication of long-term rheumatoid arthritis. Felty's syndrome is defined by the presence of three conditions: rheumatoid arthritis, an enlarged spleen, and an abnormally low white blood count. Treatment of Felty's syndrome is not always required; however, treatment for patients with infections is available.
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