Rheumatoidale Arthritis is an autoimmune condition characterized by arthritis that causes pain, swelling, heat and stiffness. It is a systemic disease that also causes fatigue, weight loss, flu-like symptoms and anemia. This condition is also unpredictable by nature, alternating with periods of high disease activity and remission. RA may initially occur in a similar way to other conditions such as polymyalgia rheumatica (PMR), other inflammatory joint diseases, and even malignancy. Symptoms may appear and disappear, so it may take months to complete the diagnosis. Can rheumatoid arthritis cause elevated liver enzymes?

Detection of signs and symptoms

RA progression is usually slow; it is believed that rapid onset occurs only in about 20% of cases. Inflammation, tenderness, and mild stiffness – usually with a symmetrical distribution – can be early symptoms, as can fatigue and weight loss. Some people delay reporting to their GP until they get serious; for this reason, patients often report irritability, anxiety and depression due to increasing pain and reduced mobility and daily activities.

Pathological features

Synovitis surrounding the joint capsules and tendon sheaths is called synovitis. The synovium is the inner membrane of tissue that lines the joint and secretes synovial fluid with the main function of lubricating the joint. Dig. 1 shows healthy joints and those that have been affected by arthritis.

Can rheumatoid arthritis cause elevated liver enzymes?
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It is suggested that pathological changes caused by synovitis occur in three stages (Hill and Ryan, 2000):

  • ¬†Cellular stage: joints become warm, swollen and delicate, causing stiffness and limited movement;
  • ¬†Inflammatory stage: granulocytes accumulate in synovial fluid before their destruction during the inflammatory process releases the lysosomal enzyme (Hill and Ryan, 2000);
  • ¬†Destructive stage: primarily affects vitreous cartilage when granulation tissue or “pannus” begins to erode the outer cartilage around the joint. Typically, synovitis initially affects the small joints of the hands and feet, although it can affect any synovial joint.

Abnormal liver function tests are not uncommon in patients with inflammatory arthritis and are usually caused by disease modifying anti-rheumatic drugs (DMARDs). Up to 22% of patients taking methotrexate will have LFT disorders at some point, with a further increase in the relationship if they have a history of liver disease or daily alcohol consumption. Most of these results are transient and not associated with significant liver damage / fibrosis.

Elevated liver enzymes in patients with rheumatoid arthritis can have various causes. They can be rheumatic diseases themselves, anti-rheumatic drugs or they can be a manifestation of a related autoimmune disease. For example, a 19-year-old woman with known seropositive rheumatoid arthritis who suffered severe liver damage after 9 months of anti-rheumatic treatment with leflunomide and adalimumab. Both drugs were stopped. In addition to the underlying disease and specific anti-rheumatic drugs, consideration should be given to temporary flucloxacillin therapy and the association with newly diagnosed celiac disease as a possible cause of elevated liver enzymes. After repeated liver biopsy, autoimmune hepatitis was established and prednisolone and azathioprine started. Elevated liver enzymes and bilirubin quickly returned to normal.

 

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