How do rheumatologists confirm diagnosis of Rheumatoid arthritis ?

A diagnosis of Rheumatoid arthritis (RA) is not just based on blood reports. There are a lot of factors which are taken into consideration by rheumatologist. Basically, there is no 100 percent test. Yes, there are two main tests, RA factor and AntiCCP. But, they can be both negative in RA patient. Also, positive RA factor or Anti CCP doesn’t mean somebody has definite RA.

Rheumatology diseases and tests are complex. Diagnosis in rheumatology is never simple like diabetes, where you check the blood sugars and you know that person has diabetes. A diagnosis of Rheumatoid or any other arthritis is based on consideration of multiple factors by a rheumatologist. A single factor or test alone cannot lead to a diagnosis in Rheumatology.

(Please understand that I have used words like maybe, likely, can be, possibly, etc. This means that none of them alone means that you have some major disease or arthritis. Everything is taken together in right context and that is why showing an expert like rheumatologist is mandatory.)

How stiff you are in the mornings – ‘Early morning stiffness EMS’?

Every person with old age or joint pains due to non-specific reason will have some stiffness. However, if there is inflammatory arthritis like RA; usually a person is worse and stiff in mornings for at least more than 30 minutes. The stiffness gradually decreases over 2-3 hours. This is known as ‘significant early morning stiffness (EMS)’. Remember, most inflammatory arthritis will have significant EMS and it can be the first sign. (eg: Psoriatic arthritis, Ankylosing spondylitis, SLE arthritis etc).

Do you have any joint swelling associated with redness, pain and warmth?

Many old age patients come to a doctor and say yes when asked if they have joint swelling. It usually is very non-specific. A rheumatologist is specifically looking for joint swelling, associated with pain and inflammation (red, warm & tender to touch). RA usually affects small joints of hands (often knuckle joints), but can affect any joint of the body.

Are ESR and CRP raised?

ESR and C-reactive protein (CRP) are markers of inflammation (Please remember CRP has nothing to do with your protein intake). If they levels are high with above complaints, it might mean that patient has some inflammatory arthritis. RA is such arthritis. Ageing can cause osteoarthritis or wear and tear arthritis, which is very different from inflammatory arthritis.

RA factor and Anti CCP in the diagnosis of RA?

Either or both of these tests can be strongly positive (levels at least 2-3 times upper limit of laboratory normal) in almost 80% of RA patients. If their levels are high with above symptoms and patient has no other disease, it is very likely that patient has Rheumatoid arthritis.

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Use of X-ray, Ultrasound (USG or sonography) and MRI in diagnosis of Rheumatoid arthritis

It is difficult to diagnose patient’s presenting to rheumatology clinic with an unclear history of joint pains and swelling. They might also have negative rheumatoid factor and anti-CCP. In such cases, we take help of X rays, USG or MRI. Xrays are not very good to detect arthritis in early stages, they are often normal. If in doubt, USG and MRI can be very helpful. They can show swelling and inflammation in joints which is not clearly visible to naked eye, hence helping us to make a diagnosis.

In clinic, rheumatologists often see patients who seem to have complaints suggesting inflammatory arthritis, but there is no obvious joint swelling. Often, their blood tests are also normal and it becomes difficult to make a proper diagnosis. Ultrasound and MRI can be helpful to detect joint inflammation in such patients, not visible to naked eye. Xrays are often normal in very early stages of arthritis.

Seronegative Rheumatoid arthritis (RA). Is any other diagnosis besides Rheumatoid arthritis possible?

Patients with other inflammatory arthritides can have similar features like above. They might also have RA factor and Anti-CCP positive. But, they also have other features to suggest a different diagnosis and other blood tests can help to make such a diagnosis, eg: Sjogren syndrome, systemic lupus erythematosus (SLE), Psoriatic arthritis etc. Sometimes a patient has inflammatory arthritis, with a pattern of RA without any conclusive test being positive. We label such patients as seronegative rheumatoid arthritis. (80)

A diagnosis of seronegative rheumatoid arthritis is given to patients who have a pattern of arthritis similar to Rheumatoid arthritis. These patients should not have features of any other arthritis and both RA factor & Anti CCP should be negative. But a good rheumatologist will always be watchful of these patients, as they might develop other definite rheumatology disease in long-term.

The following examples will help you understand why it is important to consider all factors for making a diagnosis of RA.

Case examples

Case 1 : A 45-year-old female presented with painful, swollen joints and severe stiffness in morning, lasting at least for 2 hours (significant EMS). Her symptoms had worsened for last 3 months. Her hand & wrist joints were swollen when seen in the clinic. She had high ESR & CRP with RA factor & Anti-CCP strongly positive.

Diagnosis – This is a classic presentation case of Seropositive (RA factor and/or Anti CCP positive) Rheumatoid arthritis.

Case 2 : A 35-year-old female complained of recurrent attacks of joint pain & swelling. The attacks use to occur in a different joint at different times: hands, knees, shoulder etc. The joint attacks lead to swelling, warmth and redness and patient could not move that joint for 1-2 days. The pain and swelling used to silence after taking painkillers for 1-2 days. The patient used to have one such joint attack every 2-3 months. Now she was having it every two weeks. The fear and pain of attacks made patient really miserable. She was however fine between attacks and did not have any stiffness in the mornings.

The patient had seen many doctors. By the time she managed to reach a doctor, the swelling used to settle by then. They thought ‘it’s all in her head‘. Her ESR, CRP was normal and RA factor was also negative. When the rheumatologist finally saw her, he checked her for Anti-CCP antibodies. It was strongly positive. Her ESR & CRP were highly raised when checked during attacks and became normal afterwards.

Diagnosis: Patient was having Palindromic RA (Rheumatoid arthritis).

A palindrome is a word which reads same when repeated forward and backwards, eg: civic, stats etc. Palindromic RA is kind of very early stage of RA when it has not fully developed. It presents as repeated attacks of joint pain and swelling. Unlike RA, it doesn’t have persistent swelling or symptoms. RA factor can be negative in such patients. However, if somebody with such attacks, has a rheumatoid antibody (RA factor and/or Ant-CCP) positive, they are likely to develop full-blown rheumatoid arthritis in long-term. It is very important to start treatment at this stage because such patients might need much fewer medicines in the long-term. We might also be able to delay development of full-blown Rheumatoid arthritis.

Palindromic RA is a phase where patients have recurrent attacks of joint pain and swelling. They often have a negative rheumatoid factor and by the time patient reaches a doctor, everything disappears and the doctor can’t see anything. Many such patients being young females are often labelled as having psychiatric issues by unknowing doctors. This type of presentation can be seen in many patients before they develop full-blown RA. Detecting and treating at this stage might be very helpful, as it might prevent or delay RA. Also, such patients often need fewer medicines for their RA.

Case 3 : A 70-year-old male presented with joint pains and some early morning stiffness. He was sent to a rheumatologist for a positive RA factor. He only complained of mild stiffness in mornings and that stiffness didn’t last for more than 15-20 minutes. His stiffness never disappeared completely, there was some stiffness throughout the day. There was not much change in his symptoms since last year. His ESR and CRP were marginally raised. His hands had classic wear and tear or osteoarthritis changes. His ultrasound of hand did not show any inflammation.

Diagnosis: Hand osteoarthritis (wear and tear arthritis). He had positive RA factor but did not have Rheumatoid arthritis.

Case 4: A 65-year-old female presented with progressive joint pains and stiffness lasting for an hour in mornings. Her ESR and CRP were borderline. She had negative RA factor, Anti CCP and screening for other rheumatology diseases was negative. Rheumatologist saw her and was unsure if the patient had any joint swelling. Her ultrasound showed inflammation in multiple hand joints.

Diagnosis: Seronegative (RA factor and AntiCCP negative ) Rheumatoid arthritis

Case 5: A 25-year-old female presented with pain and swelling in small joints of hands. She also had significant EMS. She had a positive RA factor. Rheumatologist found her to have arthritis with swelling and pain in her hand joints. She also complained of recent hair loss and intermittent oral ulcers since last year. A full panel revealed patient having multiple antibodies positive including ANA, dsDNA etc.

Diagnosis : SLE or lupus. Lupus management requires a very different approach from RA.

I hope this cleared many doubts. If you found this article helpful or do need any help with your rheumatology disease diagnosis, do not hesitate to comment below and contact us. We will try to reply to any query within a week. Please do look at related posts too.