If you have rheumatoid arthritis (RA) then you are familiar with the questions your rheumatologist asks at your routine office visits such as, “Are you having any joint pain, swelling, or stiffness?”, “How long do you experience stiffness in the mornings?”, and “Are your daily activities limited by your joint symptoms?”. Rheumatoid arthritis is a disease that not only affects the joints, but it can affect other organs in the body.
Here are a few warning signs of potential serious organ involvement that you should address with your doctor.
You have one joint that is swollen, red, warm, and painful, that is out of proportion to your other or usual joint pains. This could represent an infection in a single joint and should be considered an emergency. You want this to be immediately evaluated so that proper treatment, with antibiotics, can be started quickly. People with RA are at increased risk of infection, including a septic (infected) joint due to suppression of their immune systems from RA itself, as well as from the medications used to treat the RA.
Chest pressure can be a warning sign, or the presenting symptom, of a heart attack. People with RA are at an increased risk for cardiovascular disease and can develop blockages in the arteries of the heart (coronary arteries) at an earlier age than would be expected for people without RA. Thus, a chest pressure sensation in the middle of the chest, particularly if it happens when you are exerting yourself, should be taken seriously. These pains can also occur without exertion and may even happen while you’re sleeping. This symptom warrants prompt medical attention and you should go to the emergency room for an evaluation of chest pressure.
The sudden onset of back pain can be the sign of a fracture in your spine called a vertebral compression (or fragility) fracture. People with RA are at an increased risk for developing osteoporosis, or thinning of the bones, and this can result in brittle bones that fracture more easily. With a simple fall from a standing height, a fracture of the wrist, shoulder, hip or spine could occur. However, a vertebral compression fracture may occur spontaneously or with minimal trauma such as a cough, sneeze, or with lifting an item. Additionally, people with RA are often treated with prednisone, a medication that can cause increased bone loss, also called glucocorticoid (steroid) induced osteoporosis. If a vertebral compression fracture occurs, it can be very painful localized to the place in the spine with the fracture. You should see your doctor if you develop the sudden onset of back pain. Interestingly, up to three quarters of vertebral compression fractures occur without painful symptoms.
A red and painful eye. Rheumatoid arthritis can affect the eyes due to inflammation, most commonly causing scleritis or episcleritis. Scleritis is a condition when one or both eyes develop redness over the white portion of the eye, and this is both painful and can affect your vision. This is considered an emergency and should be evaluated by your doctor and/or an ophthalmologist right away. While episcleritis is not an emergency, it also causes redness of the white portion of the eye, and it can be difficult for those not specializing in eye diseases to distinguish episcleritis from scleritis. Episcleritis is uncomfortable but does not threaten your vision. It thus makes sense to see your doctor to determine if further evaluation is needed for a reddened eye. It is worth noting that this complication of RA occurs much less frequently due to the effectiveness of conventional and/or biologic medications to control RA symptoms.
Chest pain when taking a deep breath can be a sign of inflammation involving the lining of the heart (pericarditis) or of the lungs (pleurisy, pleuritis). This inflammation can also be caused by an accumulation of fluid around the heart (pericardial effusion) or lungs (pleural effusion). Pericardial or pleural inflammation often requires a modification of your RA treatment. This complication does not occur as frequently anymore now that conventional and/or biologic medications are used so successfully to treat RA.
The inability to move your ring and pinky fingers occurs when RA inflammation causes a weakening of the extensor tendons on the top of the hand. With inflammation in the wrist, this area of swelling can affect the finger extensor tendons and cause the tendons to rupture. If this occurs, it is important for you to see your doctor and a hand surgeon as soon as possible to determine if surgery is needed.
Loss of strength in a hand or foot, known as wrist drop or foot drop, can be a serious RA complication due to inflammation of the blood vessels that supply the nerves in the arm(s) or leg(s). You would notice a lack of strength in your wrist or foot to move it up against the force of gravity. This problem is called mononeuritis multiplex and is considered an emergency. If this manifestation occurs, it requires high doses of immunosuppressive medications such as corticosteroids (prednisone or methylprednisolone) as well as other medicines to suppress your immune system. Similar to previously mentioned symptoms, this one also does not occur frequently due to medication advancements in controlling RA.
Marcy Bolster is an associate professor of medicine at Harvard Medical School in the Division of Rheumatology, Allergy and Immunology. She is also the director of the Rheumatology Fellowship Training Program at Massachusetts General Hospital, Boston, MA. Dr. Bolster currently serves on the American College of Rheumatology’s Committee on Marketing and Communications.