Emerging Worlds: Chronic Illness and Viral Infections














 
  Arthritis/Rheumatism

ARTHRITIS/RHEUMATISM

DESCRIPTION Although the term is applied to a wide variety of disorders, arthritis means the inflammation of a joint, whether as the result of a disease, an infection, a genetic defect or some other cause. The inflammation causes pain, stiffness and swelling in the joints and connective tissues. Many people, however, perceive arthritis as any kind of pain or discomfort associated with body movement, including such localized problems as low back pain, bursitis, tendonitis and general stiffness or pain in the joints.

American workers lose more time to pain in the joints than to any other type of ailment. To the extent that our jobs and leisure activities become more sedentary, the likelihood of such ailments increases.

Fortunately, many of the problems commonly labeled "arthritis" are easily healed or controlled, and the prospects of debilitating complications are far less than they were for our parents and grandparents. For many -- although by no means everyone -- arthritis seems to be an inevitable part of the aging process, and there are no signs of real cures on the immediate horizon. On the positive side, advances in both conventional medical treatment and alternative therapies make living with arthritis more bearable.

Major Types of Arthritis Rheumatoid arthritis generally starts to affect people between ages 20 and 50, and women three times as frequently as men. It may occur in children, particularly girls from 2 to 5 years of age. It is characterized by inflammation and pain in the hands -- especially the knuckles and second joints -- as well as in the arms, legs, and feet, and by general fatigue and sleeplessness. It can also cause systemic damage to other parts of the body, including the heart, lungs, eyes, nerves and muscles. The discomfort of rheumatoid arthritis can develop over weeks or months and tends to be most severe on awakening.

Rheumatoid arthritis in older people may eventually cause the hands and feet to become misshapen as muscles weaken, tendons shrink, and the ends of bones become abnormally enlarged. While there is no complete cure, treatment begun at the onset of the disorder relieves symptoms in most people. With early treatment, the likelihood of permanent disability is reduced in all but 5 to 10 percent of sufferers.

Juvenile rheumatoid arthritis, or Still's disease, is characterized by chronic fever and anemia. The disease can also have secondary effects on the heart, lungs, eyes and nervous system. Arthritic episodes in children younger than the age of five can last for several weeks and may recur, although the symptoms tend to be less severe in recurrent attacks. Treatment is essentially the same as for adults, with heavy emphasis on physical therapy and exercise to keep growing bodies active. Permanent damage from juvenile rheumatoid arthritis is now rare, and most affected children recover from the disease fully without experiencing any lasting disabilities.

Osteoarthritis, or degenerative joint disease, refers to the pain and inflammation that can result from the systematic loss of cartilage in the joints. It is the most common form of arthritis, particularly in the elderly. In osteoarthritis, the protective cartilage at the ends of bones in joints -- especially in the spine and knee -- gradually wears away. The inner bone surfaces become exposed and rub together. In some cases, bony spurs develop on the edges of joints, causing damage to muscles and nerves, pain, deformity and difficulty in movement.

Although the cause of osteoarthritis is unknown, some people appear to have a genetic predisposition to degenerative bone disorders. In rare cases, congenital bone deformation appears at an early age. Misuse of anabolic steroids, which are popular among some athletes, can also bring on early osteoarthritic degeneration. Being overweight also contributes to early and more rapid progression of joint problems, especially in the knee.

In many people the onset of osteoarthritis is gradual and has no serious debilitating effect, although it can change the shape and size of bones. In other people, bony growths and gnarled joints may cause painful muscle inflammation or nerve damage, along with significant changes in posture and mobility.

Other arthritic conditions Other arthritic conditions include ankylosing spondylitis (arthritis of the spine), bone spurs (bony growths on the vertebrae or other areas), gout (crystal arthritis), and systemic lupus (inflammatory connective-tissue disease).

Infectious arthritis refers to various ailments that affect larger arm and leg joints as well as the fingers or toes. Arthritic infection is sometimes a complication of an injury or of another disease and is much less common than arthritic conditions that come on with age. Because the symptoms may be masked by the primary injury or illness, however, infectious arthritis may go unnoticed and, if left untreated, can result in permanent disability.

Causes

Each of the three major types of arthritic condition has its own apparent causes:

Rheumatoid arthritis. The cause of rheumatoid arthritis is not fully understood, though most research shows that it is an autoimmune disorder. One theory suggests that it is an immune reaction to a viral or bacterial infection somewhere in the body. Some people have a genetic or inherited factor that makes them more likely to develop rheumatoid arthritis.

Osteoarthritis. This inflammatory condition is common among the elderly. The condition may be associated with broken bones and can develop in young adults from wear and tear on the body's load-bearing joints, often as a result of intense athletic activity. In cases of osteoarthritis, the cartilage and bone cannot repair themselves sufficiently to keep up with the damage.

Infectious arthritis. This type of arthritis is caused by a bacterial or viral invasion of the joints and typically comes on the heels of another disease, such as staph infection, tuberculosis, gonorrhea or Lyme disease.

SYMPTOMS

Symptoms of arthritis include:

* Joint pain and progressive stiffness without noticeable swelling, chills, or fever during normal activities probably indicate the gradual onset of osteoarthritis.

* Painful swelling, inflammation and stiffness in the arms, legs, wrists or fingers in the same joints on both sides of the body, especially on awakening, may be signs of rheumatoid arthritis.

* Fever, joint inflammation, tenderness and sharp pain, sometimes accompanied by chills and associated with an injury or another illness, may indicate infectious arthritis.

* In children, intermittent fever, loss of appetite, weight loss, anemia, or blotchy rash on the arms and legs may signal juvenile rheumatoid arthritis.

In a healthy joint, a tough, rubbery tissue called cartilage cushions the ends of the bones at contact points. A thin membrane called the synovium lines the entire joint cavity and secretes synovial fluid to lubricate the joint.

In rheumatoid arthritis, the synovial membrane becomes thickened and inflamed. The inflammation causes cartilage to break down at the pivot point of the joint, while excess synovial fluid causes the cavity to swell.

Osteoarthritis, also called wear-and-tear arthritis or degenerative joint disease, results from gradual deterioration of cartilage in the joint after years of use. Without the protective cartilage, the bones begin to rub together, creating friction and pain.

Diagnostic and Test Procedures In addition to symptom analysis, blood tests and x-rays are commonly used to confirm rheumatoid arthritis. The majority of sufferers have antibodies called rheumatoid factors (RF) in their blood, although RF may also be present in other disorders.

X-rays are used to diagnose osteoarthritis, typically revealing shrunken joints or calcification at the ends of the bones. Sometimes blood tests and joint aspiration (using a needle to draw a small sample of fluid from the joint for testing) are used to rule out other types of arthritis. If your doctor suspects infectious arthritis as a complication of some other disease, testing a sample of fluid from the affected joint will usually confirm the diagnosis.

TREATMENT

Treatment generally includes occupational or physical therapy, exercise, medications and sometimes surgery to correct joint damage. Sometimes arthritic damage can be slowed or stopped, but in many cases the damage continues as the disease runs its course, regardless of whether drugs or other therapies are used to relieve the symptoms.

The duration and intensity of pain and discomfort depend on the type of arthritis and the degree of severity. For example, in older people with severe rheumatoid or degenerative conditions the effects may be lifelong.

Conventional Medicine

In the case of localized pain, stiffness and immobility, the typical three-stage therapy consists of medication to relieve pain and inflammation, rest to let injured tissues heal themselves, and exercise to rebuild mobility and strength.

Joint Protection. Learning to protect your joints is an important part of treatment. With the help of an occupational therapist, you can learn easier ways to do your normal activities, such as avoiding positions that strain your joints, using your strongest joints and muscles while sparing weaker ones, wearing braces or supports for certain joints, and using grab bars in the bath, modified door knobs, canes or walkers and devices to help you with tasks such as opening jars or pulling up socks. Physicians may recommend pain relievers combined with regimens of heat, rest and exercise, physical therapy, and controlled application of deep heat to soothe affected joints.

Medication. To reduce pain and inflammation in mild cases of rheumatoid arthritis and osteoarthritis, your doctor will probably prescribe aspirin or another nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen. For some conditions, such as osteoarthritis of the knee, acetaminophen is the drug of choice. Today doctors also treat early rheumatoid arthritis aggressively with disease modifying anti-rheumatoid drugs (DMARDS) such as methotrexate (chemotherapy medication).

In more advanced cases, your doctor may recommend corticosteroid injections to ease the pain and stiffness of affected joints. Depending on the individual, results range from temporary relief to long-lasting suppression of symptoms.

Early this century, researchers discovered that certain compounds containing gold, delivered orally or by injection, gave relief to some patients who have rheumatoid arthritis and caused total remission in others. Note, however, that because the side effects of gold therapy can range from minor skin rash to severe blood and kidney disorders, this therapy is generally approached with caution. Newer treatments using low doses of chemotherapy medications (methotrexate) have produced dramatic improvements in severe rheumatoid arthritis, and these types of therapy show great promise of preserving joint function. Apheresis is another treatment for rheumatoid arthritis that removes antibodies from the blood.

In cases of arthritic complications from injury or infection, specific therapy will depend on the nature and seriousness of the underlying condition. The major concern is for healing the affected area before more serious complications occur. Treatment of infectious arthritis typically involves large intravenous doses of antibiotics as well as drainage of excess fluid from the joints.

Surgery. Various forms of surgery may be needed to reduce the discomfort of arthritis or to restore mobility or joint function. Synovectomy is the removal of damaged connective tissue lining a joint cavity, and allows the body to regenerate new, healthy tissue in its place. This operation is most common in the knee. In cases of severe arthritic damage to the neck or foot, bones can be surgically removed or fused. Although movement is limited after such surgery, the operations relieve excruciating pain and help prevent further damage to nerves or blood vessels.

If arthritic pain and inflammation become truly unbearable, or arthritic joints simply refuse to function, the answer may lie in surgical joint replacement. Today, hip and shoulder joints -- as well as smaller joints in elbows, knees and fingers -- can be replaced with reliable artificial joints made of stainless steel and plastic. This type of surgery can dramatically improve function and mobility.

Pain Management. Because one of the most trying aspects of arthritis is learning to live with pain, many doctors recommend training in pain management, including cognitive therapy. The National Institutes of Health has found that cognitive behavioral therapy, using education and behavior modification alongside relaxation techniques, is better than routine care for relieving pain associated with arthritis. Such programs focus on improving patients' emotional and psychological well-being by teaching them how to relax and conduct their daily activities at a realistic pace. Learning to overcome mental stress and anxiety can be the key to coping with the physical limitations that may accompany chronic rheumatoid arthritis and osteoarthritis. Cognitive therapy may include various techniques for activity scheduling, imaging, relaxation, distraction and creative problem-solving.

Alternative Medicine

A variety of alternative therapies are used for arthritis. Let your physician know if you're considering them.

Acupuncture

Studies have shown that acupuncture helps reduce pain, may significantly lower the need for painkillers, and can help increase range of motion in affected joints.

Homeopathy may improve pain, joint tenderness, stiffness, and grip strength for those with rheumatoid arthritis, especially when used in conjunction with non-steroidal anti-inflammatories.

Supplements. Fish oil may be the best dietary supplement to try, since it has no known adverse side effects. Recommended for rheumatoid arthritis, it reduces inflammation, lessens the need for painkillers and may decrease joint stiffness. A diet low in animal and dairy fats has similar effects. Excellent sources of fish oil include EPA/DHA capsules and oily fish such as salmon and mackerel.

Supplements. Some studies suggest glucosamine and chondroitin supplements are as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) for reducing pain, swelling and stiffness in osteoarthritis, but their claims to cure or reverse joint degeneration have yet to be verified. The National Institutes of Health is conducting a large-scale study, focused on osteoarthritis of the knee, to investigate whether glucosamine can protect, build and strengthen cartilage, and if chondroitin might prevent the weakening of these same tissues. Available over the counter since 1999, the supplement SAMe has been shown in some studies to be as effective against osteoarthritic pain as NSAIDs, with the added benefit of fewer side effects.

Herbs. At least a dozen different herbs are used to ease the symptoms of both osteoarthritis and rheumatoid arthritis; most are considered anti-inflammatories. Consult your doctor about using any herbs, since they can interact with each other or with other medication you are taking. In most cases, lack of careful studies means little is known about long-term effects. Herbs to try include powdered ginger, borage seed oil or devil's claw to reduce pain and swelling. Stinging nettles or turmeric may also lessen pain, stiffness and inflammation.

Ayurvedic medicine uses herbal compounds internally and externally for symptom relief. Topical curcumin may relieve the inflammation of rheumatoid arthritis; if taken in capsule form, it can reduce morning stiffness and boost endurance. A combination of Withania somnifera, Boswellia serrata and Cucurma longa caused a significant drop in pain and disability for study subjects with osteoarthritis.

Aromatherapy. When you inhale oils or rub them on your skin, you are using the scent as well as the properties of the oil (essential fatty acids) for healing. Try thyme to relieve joint pain.

At-Home Remedies - Heat and rest, traditional remedies for arthritic pain, are very effective in the short run for most people with the disease. Overweight sufferers should lose weight, especially when arthritis affects the lower back, knees and legs. Consult a registered dietician who can help you plan a healthy weight-loss program.

If arthritic pain comes on unexpectedly, supplement an over-the-counter painkiller with dry heat from a heating pad or moist heat in the form of a hot bath or a hot-water bottle wrapped in a towel. Regular exercise is important to keep the joints mobile. People with weakened, badly deformed fingers from rheumatoid arthritis benefit from specially designed utensils and door and drawer handles; people suffering weakness in the legs and arms from osteoarthritis can use special bathroom fixtures, especially tub rails and elevated toilet seats.

PREVENTION

Though arthritis is not preventable, many patients are able to prevent disability with a well-designed exercise program.

You should call your doctor if:

* The pain and stiffness come on quickly, whether from an injury or an unknown cause; you may be experiencing the onset of rheumatoid arthritis.

* The pain is accompanied by fever; you may have infectious arthritis.

* You notice pain and stiffness in your arms, legs or back after sitting for short periods or after a night's sleep; you may be developing osteoarthritis or another arthritic condition.

* A child develops pain or a rash on armpits, knees, wrists and ankles, or has fever swings, poor appetite and weight loss; the child may have juvenile rheumatoid arthritis.

RHEUMATOID ARTHRITIS (RA)

DESCRIPTION

Rheumatoid arthritis (RA) is a chronic inflammatory condition in which the body's immune system attacks cartilage, bone, and sometimes internal organs, usually causing joint disease. More than six million Americans -- most of them women -- suffer from this potentially debilitating disease. Though the disease tends to stop by itself, any joint damage that occurred during the inflammatory phase will be permanent, sometimes causing much disability. Proper medical care may help prevent many of these problems.

Rheumatoid arthritis (RA) is a disease, in which various joints in the body are inflamed, leading to swelling, pain, stiffness, and the possible loss of function. The process begins in the synovium, the membrane that surrounds a joint and creates a protective sac. This sac is filled with lubricating liquid -- the synovial fluid. In addition to cushioning joints, this fluid supplies nutrients and oxygen to cartilage, a slippery tissue that coats the ends of bones. Cartilage is composed primarily of collagen, the structural protein in the body, which forms a mesh to give support and flexibility to joints.

In rheumatoid arthritis, continuous inflammation of the synovium gradually destroys collagen, narrowing the joint space and eventually damaging bone. In progressive RA, destruction to the cartilage accelerates when the fluid and inflammatory cells accumulate in the synovium to produce a pannus -- a growth composed of thickened synovial tissue. The pannus produces more enzymes that destroy nearby cartilage, aggravating the area and attracting more inflammatory white cells, thereby perpetuating the process. This inflammatory process not only affects cartilage and bones but can also harm organs in other parts of the body.

Risk Factors

Rheumatoid arthritis is an ancient disease; bone changes indicating the condition have been identified in skeletons thousands of years old. RA affects an estimated 2.5 million Americans -- over 60% of them women. (The risk for women is slightly lower if they have been pregnant.) Women are also at higher risk for the severe type 2 rheumatoid arthritis. (See “How Serious is Rheumatoid Arthritis?” section below.) Although the disease can occur at any age from childhood to old age, it usually starts in young adulthood, with age of onset peaking between 20 and 45. The risk increases in those with relatives who have rheumatoid arthritis.

One study suggests that smoking, obesity, and a history of prior blood transfusion are all significant risk factors for the development of RA. Reports from a recent Dutch study suggest that hay fever sufferers have a reduced risk of developing rheumatoid arthritis, and, conversely, arthritis patients are less likely to have hay fever. Having a history of major depression that persists or reoccurs seems to increase the pain, disability, and fatigue experienced by patients with arthritis. It should be noted that, contrary to public reports, most studies are not finding any association between silicone breast implants and rheumatoid arthritis or other autoimumune disease (except possibly Sjogren's syndrome). Implants also do not appear to increase the risk for these diseases in breast-fed babies.

CAUSES

Rheumatoid arthritis is one of several "autoimmune" diseases ("auto" means self), so-called because a person's immune system attacks his or her own body tissues. Scientists still do not know exactly what causes this to happen, but research over the last few years has begun to unravel the factors involved.

Many scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis. An infectious agent such as a virus or bacterium appears likely, but the exact agent is not yet known. Note, however, that rheumatoid arthritis is not contagious: A person cannot "catch" it from someone else.

One prevalent theory is that a combination of factors trigger rheumatoid arthritis, including genetic susceptibility, an abnormal autoimmune response, and a viral infection.

The Inflammatory Process The inflammatory process is a byproduct of the body's immune system, which fights infection and heals wounds and injuries. When an injury or an infection occurs, white blood cells are mobilized to rid the body of any foreign proteins, such as a virus. The masses of blood cells that gather at the injured or infected site cause the area to become inflamed. Under normal conditions, the inflammatory process is controlled and self-limited, but in people with chronic rheumatoid arthritis, certain defects, probably genetic, keep this process going.

The primary infection-fighting units are two types of white blood cells -- lymphocytes and leukocytes. Lymphocytes include two subtypes known as T-cells and B-cells. Normally, when a foreign agent infects the body, helper T-cells recognize that the invader, known as an antigen, is an alien and trigger a series of immune responses to destroy it. In rheumatoid arthritis, however, a process called autoimmunity occurs. The T-cells mistake the bodys’ own collagen cells as foreign antigens and set off a series of events to rid the body of the perceived threat. Initial events include stimulation of lymphocyte B cells to produce antibodies -- molecules designed for attack on a specific antigen. When these antibodies attack the body's own tissue, they are called autoantibodies.

The leukocytes are the other major white blood cells that are spurred into action by the overactive T-cells. Leukocytes stimulate the production of two key players in the inflammatory process: leukotrienes, which attract even more white blood cells to the area, and prostaglandins, which open blood vessels and increase blood flow. As part of their activity, leukocytes also produce cytokines -- small proteins that many researchers believe are critical in the process that leads to joint damage and may even be responsible for inflammation that occurs in parts of the body beyond the joints. In small amounts, these powerful chemicals are indispensable for healing. If overproduced, however, cytokines can cause serious damage, including fever, shock, and even damage to organs, such as the liver. Important cytokines in the process of rheumatoid arthritis are those known as tumor necrosis factor and interleukins. Some cytokines play a role in releasing enzymes, such as those known as collagenase and cathepsin L, which destroy collagen. One of the most important cytokines currently targeted in rheumatoid arthritis research is tumor necrosis factor; levels of this cytokine soar in the synovial fluid during arthritic flare-ups. Others under study are interferon, GM-CSF, and interleukins 1, 6, 9, 11, and 15. Excessive amounts of nitric oxide, a substance important in blood vessel flexibility and dilation, may also play a major destructive role in RA.

Genetic Factors

Scientists have found that certain genes that play a role in the immune system are associated with a tendency to develop rheumatoid arthritis. At the same time, some people with rheumatoid arthritis do not have these particular genes, and other people have these genes but never develop the disease. This suggests that a person's genetic makeup is an important part of the story but not the whole answer. It is clear, however, that more than one gene is involved in determining whether a person develops rheumatoid arthritis and, if so, how severe the disease will become.

HLA-DR4. HLA is genetic type that produces molecules that trap antigens, which are then targeted and attacked by the immune system. Researchers have identified a molecule called HLA-DR4, which is present in many patients with autoimmune conditions. In people who have this genetic susceptibility, the immune system may be tricked into attacking collagen protein because of its resemblance to some actual foreign antigen, such as a virus. HLA-DR4, however, is also present in many people who do not contract RA, and many experts believe that more than one gene must be involved in order for the disease to develop.

Lack of Corticotropin-Releasing Hormone. Some people may have a genetic deficiency of a hormone, known as corticotropin-releasing hormone (CRH), which produce corticosteroids, other hormones that suppress the inflammatory process.

P53. Even successful treatment of the inflammation does not completely prevent further joint destruction. Research has found the presence of a mutated gene known as p53 in synovial tissue obtained from a group of patients. In such cases, the mutation is not inherited but appears to develop as part of the disease process. In its normal state, the p53 gene is known as a tumor suppressor gene and causes apoptosis, a natural process by which cells self-destruct. When the p53 gene is defective, cells do not die but continue to reproduce; such actions may help explain the development of a pannus -- a growth that occurs in RA composed of thickened synovial tissue -- and the further destruction of cartilage and bone even after the inflammation has been treated. A p53 mutation is found in many cancers. In RA, although the defective p53 gene behaves differently, the risk for certain cancers is higher than normal in patients with rheumatoid arthritis. It is not known, however, whether the p53 has any role in this increased risk.

Infectious Triggers

Although many bacteria and viruses have been studied, no single organism has been proven to be the primary trigger for the autoimmune response and subsequent damaging inflammation. Higher than average levels of antibodies that react with the common intestinal bacteria E. coli have appeared in the synovial fluid of people with RA, which some experts think may stimulate the immune system to perpetuate RA once the disease has been triggered by some other initial infection.

SYMPTOMS

The hallmark symptom of rheumatoid arthritis is morning stiffness that lasts for at least an hour. (Stiffness from osteoarthritis, for instance, usually clears up within half an hour.) Even after remaining motionless for a few moments, the body can stiffen; movement becomes easier again after loosening up.

Symptoms such as fatigue, weight loss, and fever may accompany early rheumatoid arthritis. Some people describe them as being similar to those of a cold or flu, except, of course, RA symptoms can last for years. Swelling and pain in the joints must occur for at last six weeks before a diagnosis of rheumatoid arthritis is considered. Although rheumatoid arthritis almost always develops in the wrists and knuckles, the knees and joints of the ball of the foot are often affected as well. Indeed, many joints may be involved. The pain often occurs symmetrically but may be more severe on one side of the body, depending on which hand the person uses more often. It does not usually show up in the fingertips, where osteoarthritis is common, but joints at the base of the fingers are often painful. The inflamed joints are usually swollen and often feel warm and "boggy" when touched.

In about 20% of people with RA, inflammation of small blood vessels can cause nodules, or lumps, under the skin. They are about the size of a pea or slightly larger, and are often located near the elbow, although they can show up anywhere. Nodules can occur throughout the course of the disease; they are usually painless, but rarely they can reflect the presence of rheumatoid vasculitis, a condition that can affect blood vessels in the lungs, kidneys, or other organs. Rarely, nodules may become sore and infected, particularly if they are in locations where stress occurs, such as ankles.

Fluid may accumulate, particularly in the ankles. In rare cases, the joint sac behind the knee accumulates fluid and forms what is known as a Baker cyst; it feels like a tumor and sometimes extends down the back of the calf causing pain.

In children, juvenile rheumatoid arthritis, also known as Still's disease, is usually preceded by high fever and shaking chills along with pain and swelling in many joints. A pink skin rash may be present and internal organs, such as the lungs and heart, may be involved.

How Serious Is Rheumatoid Arthritis?

Some experts classify rheumatoid arthritis as type 1 or type 2. Type 1, the less common form, lasts a few months at most and leaves no permanent disability.

Type 2 is chronic and lasts for years, sometimes for life. Treatments for RA are increasingly effective in slowing down this debilitating disease, and some may even prevent initial destruction by aggressively reducing inflammation. It is essential, therefore, to seek a physician's help as soon as symptoms develop. It should be noted, that side effects of the treatments themselves often contribute to the severity of the disease. Affected joints can become deformed, and the performance of even ordinary tasks may be very difficult or impossible. According to a recent survey, 70% of patients with rheumatoid arthritis feel the disease prevents them from living a fully productive life. RA can cause anemia and affect the nerves. RA patients are at special risk for scleritis, an inflammation of the blood vessels in the eye that could result in corneal damage. One small study found a very high prevalence of lung disease in newly diagnosed RA patients, although other studies have reported an association between a history of smoking and a higher risk for RA, which may partially account for this finding. (Cigarette smoking, in any case, may increase the severity of the disease.) RA is also associated with a higher risk for certain other cancers of the blood, particularly lymphoma. Alterations in the immune system may pla

 
 
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