Vasculitis may accompany
rheumatoid arthritis. One must distinguish between vascular involvement associated with the pathogenesis of
rheumatoid arthritis, isolated digital
vasculitis, and the syndrome of clinical
rheumatoid vasculitis. The cause of clinical
rheumatoid vasculitis is unknown. High titers of
rheumatoid factor,
cryoglobulins, diminished circulating
complement, an increased prevalence of
HLA-DR4, and the pathologic findings suggest an immune etiology. However, similar, but perhaps less pronounced, abnormalities occur in uncomplicated
rheumatoid arthritis, and these findings are not universal in complicating
vasculitis. Classic cutaneous clinical manifestations include ischemic
ulcers, digital
gangrene, and palpable
purpura.
Mononeuritis multiplex is another classic presentation of
rheumatoid vasculitis. Small digital
infarctions may accompany other manifestations in clinical
vasculitis or may occur alone as isolated digital
arteritis, in which case the prognosis is relatively favorable.
Weight loss,
pleuritis,
pericarditis, ocular
inflammation,
splenomegaly,
hepatomegaly, and
Felty's syndrome have also been reported in association with
rheumatoid vasculitis. Although renal involvement has been considered unusual in
rheumatoid vasculitis, several studies suggest that this may be more common than previously recognized. Ideally, a biopsy or an angiogram confirms the diagnosis of
rheumatoid vasculitis, but often the diagnosis rests upon the clinical picture. In general, blind biopsies are not helpful, although one series indicated that a blind rectal biopsy may be an exception to this rule. An elevated erythrocyte sedimentation rate, increased
C-reactive protein level,
anemia,
thrombocytosis,
hypoalbuminemia, and a positive
rheumatoid factor are common laboratory findings.
Leukocytosis, hypergammaglobinemia,
leukocytopenia, an elevated
creatinine level, and minimal abnormalities of the urinary sediment also occur in patients with
rheumatoid vasculitis. However, these abnormalities overlap in patients with uncomplicated
rheumatoid arthritis, and their role in distinguishing
rheumatoid vasculitis from uncomplicated
rheumatoid arthritis is limited. Other immunologic tests have no established clinical role in diagnosing
rheumatoid vasculitis.
Therapy depends upon the clinical manifestation of
rheumatoid vasculitis. Uncomplicated
rheumatoid arthritis deserves appropriate
therapy, and general attention to nutrition, cessation of tobacco, and control of blood pressure are indicated for all patients. Isolated digital
vasculitis generally requires no more than the usual treatment for uncomplicated
rheumatoid arthritis. Appropriate dermatologic management is indicated for ischemic
ulcers. Most clinical experience in managing more symptomatic
rheumatoid vasculitis has focused on glucocorticosteroids,
D-penicillamine, and cytotoxic immunosuppressive drugs.(ABSTRACT TRUNCATED AT 400 WORDS)