RA Symptoms: Are They Related to Vasculitis?

Vasculitis? Rheumatoid Arthritis (RA)?

Hello, doctor.
I have been diagnosed with rheumatoid arthritis (RA) at a medical center due to polyarticular pain and a strongly positive anti-CCP test.
I have been on medication for quite some time.
Recently, I have been experiencing recurrent oral ulcers (not severe and not very painful), small rashes on my limbs (with tiny blood spots that crust over, also not severe), tinnitus when lying flat for over a month, frequent small petechiae on my body (not severe), and asthma (which occurs often but is not severe).
My lab results for CBC, ESR, CRP, C3, and C4 are mostly normal, with occasional slight deviations.
I have regular follow-ups in both northern and central Taiwan, and one doctor seems to suspect a vasculitis issue, while another is still evaluating the possibility of systemic lupus erythematosus (SLE) since literature indicates a dsDNA detection rate of 40% to 70%, and even normal results do not rule it out.
I am trying hard to maintain my immune system close to normal through my daily routine and careful dietary choices.

I would like to ask if the aforementioned symptoms are related to RA? Should I be concerned? I feel that whenever I mention these minor symptoms, my medication list seems to grow...
Long-term treatment and medication have left me feeling quite down; I currently take 12 different medications.
Sometimes, I consider reducing my medication on my own...
It feels like following the prescribed treatment is akin to making a deal with the devil, as it seems that neither the liver nor the kidneys can escape the adverse effects of the drugs...
The more I think about it, the more anxious I become...
However, not seeing a doctor and taking medication might lead to even more serious consequences...
I often feel a sense of despair.
From your responses to other patients, I feel you are an exceptionally caring doctor...
So while asking questions, I also wanted to vent my frustrations.
Thank you very much for taking the time to respond to us, the distressed patients.

VRA, 40~49 year old female. Ask Date: 2013/12/13

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your message.
Based on the symptoms you described, vasculitis is a possibility, and rheumatoid arthritis (RA) can also lead to vasculitis.
However, vasculitis associated with RA typically occurs when medication control is inadequate or treatment is irregular.
If you are consistently taking your medications, the likelihood of developing vasculitis as a complication of RA is actually low.

Regarding the differing opinions among physicians, this can happen in rheumatology, as some rheumatic diseases have complex and variable courses and clinical presentations, especially systemic lupus erythematosus (SLE) and Sjögren's syndrome.
Long-term follow-up and medication adjustments based on changes in the condition are necessary.

My suggestion is that having 12 different medications does seem a bit excessive.
You might want to discuss simplifying your medication regimen with your physician.
After all, some medications can be used across different rheumatic diseases, and carefully selecting medications can reduce the number of drugs a patient needs to take, improve medication adherence, and alleviate patient anxiety.
Physicians are generally supportive of efforts to simplify medication regimens.
You can express to your doctor that you feel overwhelmed by the number of medications you are taking; physicians today are very attentive to patient feedback, so there’s no need to worry.
Additionally, when your condition is stable, I recommend engaging in joint-friendly exercises.
Regular physical activity can help soothe immune function and enhance the coordination of muscles and joints, which can reduce pain flare-ups and alleviate unnecessary tension—it's a win-win approach worth trying.

The Allergy, Immunology, and Rheumatology Department at Changhua Hospital, Ministry of Health and Welfare, cares about your well-being.

Reply Date: 2013/12/13

More Info

Rheumatoid arthritis (RA) is a chronic autoimmune condition that primarily affects the joints but can also have systemic implications, including the potential for vasculitis. Your symptoms, including oral ulcers, skin rashes, tinnitus, petechiae, and asthma-like symptoms, raise important questions about their relationship to RA and the possibility of vasculitis or other autoimmune conditions.

1. Understanding Your Symptoms:
- Oral Ulcers: These can occur in RA patients, although they are more commonly associated with conditions like Behçet's disease or systemic lupus erythematosus (SLE).
- Skin Rashes and Petechiae: The small rashes and petechiae you describe could be indicative of vasculitis, which is inflammation of the blood vessels. In RA, this can occur, especially if the disease is not well-controlled. However, these symptoms can also arise from other causes, including medication side effects or other dermatological conditions.

- Tinnitus: This symptom is less commonly associated with RA but can occur due to various reasons, including medication side effects or other underlying conditions.

- Asthma-like Symptoms: RA can lead to pulmonary complications, including bronchial inflammation, which might manifest as asthma-like symptoms.
2. Laboratory Findings:
- Your normal CBC, ESR, CRP, C3, and C4 levels suggest that there is no significant systemic inflammation at this time. However, it is important to note that these tests can sometimes miss subtle inflammatory processes, especially in the context of autoimmune diseases.

3. Differential Diagnosis:
- The suspicion of vasculitis by one physician and the consideration of SLE by another is not uncommon in complex cases like yours. Both conditions can present with overlapping symptoms, and it is crucial to conduct a thorough evaluation to rule out or confirm these diagnoses. The presence of anti-dsDNA antibodies, while suggestive of SLE, is not definitive, especially if other clinical features do not align.

4. Management and Treatment:
- It is understandable to feel overwhelmed by the number of medications you are taking. Managing RA often requires a careful balance of medications to control inflammation while minimizing side effects. It is essential to communicate your concerns about medication burden with your healthcare provider. They may be able to simplify your regimen or adjust dosages to alleviate your fears about potential drug toxicity to your liver and kidneys.

- Regular monitoring of your renal and hepatic function is crucial, especially when on multiple medications. This can help mitigate the risks associated with long-term medication use.

5. Mental Health Considerations:
- The emotional toll of living with a chronic illness like RA can be significant. Feelings of anxiety and depression are common among patients with chronic conditions. It may be beneficial to seek support from mental health professionals or support groups where you can share your experiences and feelings.

6. Lifestyle Modifications:
- Maintaining a healthy lifestyle, including a balanced diet, regular exercise (as tolerated), and stress management techniques, can help improve your overall well-being and potentially reduce the frequency and severity of flare-ups.

In conclusion, while some of your symptoms may be related to RA, others could indicate additional underlying issues, such as vasculitis or SLE. It is essential to continue working closely with your healthcare team to monitor your symptoms and adjust your treatment plan as necessary. Open communication about your concerns and experiences will help ensure that you receive the most appropriate care for your condition.

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