Worrisome Symptoms that May Be Linked to Rheumatoid Arthritis

While Rheumatoid Arthritis (RA) primarily affects the joints, it also increases the risk of developing other serious medical conditions. These conditions can affect anything from vision and hearing to bone density and lung function. Without treatment, these conditions can have a significant effect on overall health and lifestyle.

Below are several symptoms and medical conditions that may be linked to rheumatoid arthritis. Most of these conditions are uncommon, and they are more likely to develop when rheumatoid arthritis is either longstanding or not well-managed. In addition, treatments are often available to help manage symptoms and limit possible long-term effects.

Eye Dryness, Irritation, Pain, or Blurred Vision

Several conditions that affect the eyes are associated with rheumatoid arthritis. These conditions may be temporary or life-long and can cause a wide range of symptoms.

• Sjögren’s syndrome can cause dry eye as well as dry mouth. This condition affects the body’s ability to produce saliva and tears. About 30% of people with RA develop Sjögren’s syndrome. ¹ Harrold LR, Shan Y, Rebello S, et al. Prevalence of Sjögren's syndrome associated with rheumatoid arthritis in the USA: an observational study from the Corrona registry. Clin Rheumatol. 2020;39(6):1899-1905. doi: 10.1007/s10067-020-05004-8
• Keratoconjunctivitis sicca ² Zlatanović G, Veselinović D, Cekić S, Zivković M, Dorđević-Jocić J, Zlatanović M. Ocular manifestation of rheumatoid arthritis-different forms and frequency. Bosn J Basic Med Sci. 2010;10(4):323-327. doi:10.17305/bjbms.2010.2680 PMCID: PMC5489043 ^{, 3} Murray PI, Rauz S. The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis. Best Pract Res Clin Rheumatol. 2016;30(5):802-825. doi:10.1016/j.berh.2016.10.007 PMID: 27964790 affects 15% to 25% of people with RA. ⁴ Kadayifcilar S. Rheumatoid arthritis. In: Roy FH, Fraunfelder FW, Fraunfelder FT, Tindall R, Jensvold B, eds. Roy and Fraunfelder's Current Occular Therapy, 6th Ed. W.B. Saunders; 2008: 169-171. Accessed July 16, 2021 https://www.sciencedirect.com/sdfe/pdf/download/eid/3-s2.0-B9781416024477500992/first-page-pdf/a> This condition occurs when the eyes cannot produce enough tears. The lack of moisture may cause eyes to feel dry, irritated, itchy, burning, and/or sensitive to light.
• Episcleritis ² Zlatanović G, Veselinović D, Cekić S, Zivković M, Dorđević-Jocić J, Zlatanović M. Ocular manifestation of rheumatoid arthritis-different forms and frequency. Bosn J Basic Med Sci. 2010;10(4):323-327. doi:10.17305/bjbms.2010.2680 PMCID: PMC5489043 can cause eye irritation, redness, and swelling. Episcleritis may only affect one small part of an eyeball. The affected area may appear raised, red, and/or yellowish. This condition typically goes away on its own, but it can be treated medically.
• Scleritis ² Zlatanović G, Veselinović D, Cekić S, Zivković M, Dorđević-Jocić J, Zlatanović M. Ocular manifestation of rheumatoid arthritis-different forms and frequency. Bosn J Basic Med Sci. 2010;10(4):323-327. doi:10.17305/bjbms.2010.2680 PMCID: PMC5489043 ^{, 3} Murray PI, Rauz S. The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis. Best Pract Res Clin Rheumatol. 2016;30(5):802-825. doi:10.1016/j.berh.2016.10.007 PMID: 27964790 can cause deep aching pain in the eye. The eye may water excessively and be sensitive to light. Part or all of the eye may become discolored, appearing red or purple. This is an uncommon but serious condition that can permanently affect vision.
• Keratitis, ² Zlatanović G, Veselinović D, Cekić S, Zivković M, Dorđević-Jocić J, Zlatanović M. Ocular manifestation of rheumatoid arthritis-different forms and frequency. Bosn J Basic Med Sci. 2010;10(4):323-327. doi:10.17305/bjbms.2010.2680 PMCID: PMC5489043 ^{, 3} Murray PI, Rauz S. The eye and inflammatory rheumatic diseases: The eye and rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis. Best Pract Res Clin Rheumatol. 2016;30(5):802-825. doi:10.1016/j.berh.2016.10.007 PMID: 27964790 or inflammation of the cornea, can cause blurred vision and sensitivity to bright light. It may feel like there is something stuck in the eye.

Report changes in vision to a health care provider immediately.

Shortness of Breath or Coughing

The lungs are often affected in people diagnosed with rheumatoid arthritis. Lung conditions may cause coughing, shortness of breath, and chest pain. Rarely, these conditions become life-threatening.

• Interstitial lung disease is an umbrella term used to describe many disorders that cause scarring of the walls of the lungs and certain nearby structures. In people with RA, scarring is typically caused by chronic inflammation. The initial symptoms of interstitial lung disease typically include shortness of breath and a cough.
• Pleural effusion, also called pulmonary effusion or water on the lungs, occurs when fluid collects in the chest cavity outside the lungs. Pleural effusion can cause sharp chest pain, coughing, and shortness of breath. It may be noticeably more difficult to breathe when lying down.
• Nodules in the lungs typically have no symptoms but may increase the risk for potentially life-threatening conditions, such as a collapsed lung. ⁵ Vantrease A, Trabue C, Atkinson J, McNabb P. Large endocardial rheumatoid nodules: a case report and review of the literature. J Community Hosp Intern Med Perspect. 2017;7(3):175-177. Published 2017 Jul 13. doi:10.1080/20009666.2017.1340731 PMCID: PMC5538220 ^{, 6} Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med. 2019;40(3):545-560. doi:10.1016/j.ccm.2019.05.003 PMCID: PMC6994971 Rheumatoid nodules in the lungs are rare and account for less than 1% of all rheumatoid nodules.

The chances of developing lung conditions related to RA are increased by smoking.

Shortness of breath or coughing and risk of lymphoma

Rarely, shortness of breath or coughing is a sign of lymphoma, which is a cancer of the blood and lymph system. RA doubles the chances of getting lymphoma, raising the lifetime risk from about 2% to 4%. ⁷ Whelan P. Der Zusammenhang zwischen rheumatoider Arthritis und Krebs [Link between rheumatoid arthritis and cancer]. Z Rheumatol. 2006;65(6):497-504. doi:10.1007/s00393-006-0105-9 PMID: 17004050 ^{, 8} Klein A, Polliack A, Gafter-Gvili A. Rheumatoid arthritis and lymphoma: Incidence, pathogenesis, biology, and outcome. Hematol Oncol. 2018;36(5):733-739. doi:10.1002/hon.2525 PMID: 29862535

Other signs and symptoms of lymphoma include swollen lymph nodes, weight loss, itchy skin, and/or night sweats. Swollen lymph nodes appear as lumps under the skin. Unlike rheumatoid nodules, these lumps are most likely to appear in the groin, armpit, or neck.

Chest Pain or a Racing, Pounding Heart

Inflammation from rheumatoid arthritis may worsen or trigger heart problems. These heart problems include, but may not be limited to:

• Coronary heart disease, also known as coronary artery disease or clogged arteries, is 1.5 to 2 times more common in people with RA than in the general population. ⁹ Crowson CS, Liao KP, Davis JM 3rd, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013;166(4):622-628.e1. doi:10.1016/j.ahj.2013.07.010 PMID: 24093840 Coronary heart disease can lead to heart attack and stroke. It can cause a variety of symptoms, including shortness of breath and tightness in the chest, especially during physical activity.
• Pericarditis is inflammation of the delicate membrane that surrounds the heart, called the pericardium. Pericarditis can cause sudden chest pain and may be mistaken for a heart attack.
• Myocarditis is inflammation of the heart muscle itself. It can cause damage to heart tissue and—depending on severity and treatment—may be life-threatening. Myocarditis symptoms vary and may include fatigue, shortness of breath, swelling (edema), and chest pain. The heart may feel like it is racing, fluttering, or pounding.

A physician may refer to any one of these conditions as cardiovascular disease, which is an umbrella term used for all types of diseases that affect the heart or blood vessels. Cardiovascular disease is a leading cause of death in the United States.

Skin Rashes or Open Sores

Visible changes to the skin are occasionally associated with rheumatoid arthritis. Rashes and open sores (also called ulcers or lesions) may be painful, itchy, or burning. While these skin abnormalities frequently develop on the lower legs, they can appear anywhere on the body.

Rashes and sores that may be associated with RA can vary widely in appearance. Examples include the following:

• Rheumatoid small-cell vasculitis ¹⁰ Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol. 2019;33(4):101440. doi:10.1016/j.berh.2019.101440 PMID: 31585842 ^{, 11} Tilstra JS, Lienesch DW. Rheumatoid Nodules. Dermatol Clin. 2015;33(3):361-371. doi:10.1016/j.det.2015.03.004 PMID: 26143419 can cause a rash of dark red or purple bumps on the skin. The bumps may form lesions and scab over.
• Urticarial vasculitis ¹⁰ Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol. 2019;33(4):101440. doi:10.1016/j.berh.2019.101440 PMID: 31585842 causes hives or raised pink patches. The patches may have whitish centers. On darker skin, changes in skin color may be less noticeable, but the skin will still be raised.
• Panniculitis ¹⁰ Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol. 2019;33(4):101440. doi:10.1016/j.berh.2019.101440 PMID: 31585842 refers to a family of conditions that cause painful red or purple lumps to develop on the lower legs. The most common type of panniculitis, erythema nodosum, may look like multiple bruises on the shins.
• Pyoderma gangrenosum ¹⁰ Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol. 2019;33(4):101440. doi:10.1016/j.berh.2019.101440 PMID: 31585842 typically begins as small red bumps that expand into painful open sores, sometimes in a matter of days. This condition is very rare and typically affects the skin on the lower legs.
• Infections may cause red or pink skin and eruptions that look like blisters or pimples. The affected area may ooze fluid or be crusted over.

Research shows that using biologic medications increases the risk for skin infections and rashes, including psoriasis. ¹² Sehgal R, Stratman EJ, Cutlan JE. Biologic Agent-Associated Cutaneous Adverse Events: A Single Center Experience. Clin Med Res. 2018;16(1-2):41-46. doi:10.3121/cmr.2017.1364 PMCID: PMC6108513 ^{, 13} Pasadyn SR, Knabel D, Fernandez AP, Warren CB. Cutaneous adverse effects of biologic medications. Cleve Clin J Med. 2020;87(5):288-299. doi:10.3949/ccjm.87a.19119 For example, a 14-year study of 583 people who took biologics found nearly 12% (68 people) experienced at least one skin infection and more than 10% (59 people) had at least one bout of psoriasis. ¹⁴ Fréling E, Baumann C, Cuny JF, et al. Cumulative incidence of, risk factors for, and outcome of dermatological complications of anti-TNF therapy in inflammatory bowel disease: a 14-year experience. Am J Gastroenterol. 2015;110(8):1186-1196. doi:10.1038/ajg.2015.205

See Risks and Side Effects of Biologics

Rashes in the early stages RA

While not common, skin rashes may appear along with the first signs and symptoms of rheumatoid arthritis. ¹⁰ Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol. 2019;33(4):101440. doi:10.1016/j.berh.2019.101440 PMID: 31585842 The diagnosing physician will need to rule out other autoimmune conditions, such as lupus and psoriatic arthritis, that are more likely to cause skin abnormalities.

Foamy, Pink, or Brown Urine

Research suggests 30% of people with RA experience kidney problems at some point, ¹⁵ Saccon F, Gatto M, Larosa M, et al. Diagnostic and prognostic role of renal histopathology in rheumatic diseases. Reumatismo. 2018;70(3):165-177. Published 2018 Oct 3. doi:10.4081/reumatismo.2018.1064 though only a portion will develop chronic kidney disease. The kidneys filter blood, removing waste and excess water to create urine. When there is a problem with the kidneys, urine may look different—possibly foamy, pink, or brown.

Kidney problems can also cause:

• Fatigue and/or insomnia
• High blood pressure
• Shortness of breath
• Swelling in the lower leg, ankles, and feet
• Puffy eyes
• Poor appetite
• Muscle cramping

Swelling related to kidney problems may also be less tender and painful than swelling related to an RA flare.

Kidney problems may be the result of:

• Body-wide inflammation related to RA
• Medications used to treat RA, including but not limited to methotrexate and nonsteroidal anti-inflammatory drugs (NSAIDs), such as Aleve, Advil, and Celebrex

The most common kidney problems associated with RA include mesangial glomerulonephritis (GN), membranous nephropathy, and secondary amyloidosis. ¹⁵ Saccon F, Gatto M, Larosa M, et al. Diagnostic and prognostic role of renal histopathology in rheumatic diseases. Reumatismo. 2018;70(3):165-177. Published 2018 Oct 3. doi:10.4081/reumatismo.2018.1064 Making an exact diagnosis typically requires a surgical biopsy and is not always necessary for treatment.

While kidney conditions can be serious and lead to chronic kidney disease, they may also be relatively mild or reversible with treatment. Physicians must evaluate each person individually.

Recommended treatment may include changes to medication, especially if medications are the suspected cause of kidney problems. Other first-line treatments may include taking steps to control blood pressure and making lifestyle changes, such as changing diet, exercising regularly, and quitting tobacco products. ¹⁶ Preventing Chronic Kidney Disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/managing

Broken or Brittle Bones

Rheumatoid arthritis is associated with a loss in bone mineral density, ¹⁷ Hu Z, Zhang L, Lin Z, et al. Prevalence and risk factors for bone loss in rheumatoid arthritis patients from South China: modeled by three methods. BMC Musculoskelet Disord. 2021;22(1):534. Published 2021 Jun 12. doi:10.1186/s12891-021-04403-5  PMCID: PMC8199806 ^{, 18} Kweon SM, Sohn DH, Park JH, et al. Male patients with rheumatoid arthritis have an increased risk of osteoporosis: Frequency and risk factors. Medicine (Baltimore). 2018;97(24):e11122. doi:10.1097/MD.0000000000011122 PMCID: PMC6023711 which is the hallmark sign of osteoporosis. In fact, osteoporosis is considered typical in people who have had rheumatoid arthritis for a long time. ¹⁹ Kalliolias GD and Skokos D. Immunological Basis of Inflammatory Arthritides, In: P. Efthimiou (ed.) Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed August 15, 2021. https://doi.org/10.1007/978-3-030-23022-7_15

Certain medications can also increase the risk of developing osteoporosis and its precursor, osteopenia. For example, prednisone and other corticosteroids, which may be prescribed to treat newly diagnosed RA and RA flares, are associated with a loss of bone mineral density. ²⁰ Rife E, Nkechinyere E, Leon de la Rocha J. Glucocorticoid-Induced Osteoporosis: Are We Practicing Prevention? [abstract]. Arthritis Rheumatol. 2020; 72 (suppl 10). Accessed June 23, 2021. https://acrabstracts.org/abstract/glucocorticoid-induced-osteoporosis-are-we-practicing-prevention/

Osteoporosis causes bones to become porous and weaker. Osteoporotic bones are:

• More prone to breaking
• Less suitable for joint replacement or other orthopedic surgeries

A bone break can have a negative effect on joint mechanics, even after the bone has healed, increasing the risk for osteoarthritis.

Puffy, Bleeding Gums

Poor oral hygiene has been linked to rheumatoid arthritis and worsening RA symptoms. ²¹ Rodríguez-Lozano B, González-Febles J, Garnier-Rodríguez JL, Dadlani S, Bustabad-Reyes S, Sanz M, Sánchez-Alonso F, Sánchez-Piedra C, González-Dávila E, Díaz-González F. Association between severity of periodontitis and clinical activity in rheumatoid arthritis patients: a case-control study. Arthritis Res Ther. 2019 Jan 18;21(1):27. doi: 10.1186/s13075-019-1808-z. PMID: 30658685 It can even increase the risk of developing RA. ²² Gomez-Bañuelos E, Johansson L, Konig MF, Lundquist A, Paz M, Buhlin K, Johansson A, Rantapää-Dahlqvist S, Andrade F. Exposure to Aggregatibacter actinomycetemcomitans before Symptom Onset and the Risk of Evolving to Rheumatoid Arthritis. J Clin Med. 2020 Jun 18;9(6):1906. doi: 10.3390/jcm9061906. PMID: 32570853 ^{, 23} Konig MF, Abusleme L, Reinholdt J, Palmer RJ, Teles RP, Sampson K, Rosen A, Nigrovic PA, Sokolove J, Giles JT, Moutsopoulos NM, Andrade F. Aggregatibacter actinomycetemcomitans-induced hypercitrullination links periodontal infection to autoimmunity in rheumatoid arthritis. Sci Transl Med. 2016 Dec 14;8(369):369ra176. doi: 10.1126/scitranslmed.aaj1921. PMID: 27974664

Rheumatoid arthritis (RA) has been linked to ²⁴ Mercado FB, Marshall RI, Klestov AC, Bartold PM. Relationship between rheumatoid arthritis and periodontitis. J Periodontol. 2001 Jun;72(6):779-87. doi: 10.1902/jop.2001.72.6.779. PMID: 11453241. ^{, 25} Bartold PM, Marshall RI, Haynes DR. Periodontitis and rheumatoid arthritis: a review. J Periodontol. 2005 Nov;76(11 Suppl):2066-74. doi: 10.1902/jop.2005.76.11-S.2066. PMID: 16277578. :

• Gingivitis (gum inflammation), which causes gums to be irritated, swollen, and red
• Periodontitis (gum disease), which causes gums to bleed and recede and may result in bad breath, teeth shifting, and tooth loss

Gingivitis is reversible with treatment, including regular dental cleanings and home care that includes daily brushing and flossing. Periodontitis is more challenging to treat than gingivitis and may include medical treatment. Severe cases may be treated with surgery.

Improved oral health and may help ease rheumatoid arthritis symptoms, such as joint tenderness and swelling. ²⁶ Sun J, Zheng Y, Bian X, Ge H, Wang J, Zhang Z. Non-surgical periodontal treatment improves rheumatoid arthritis disease activity: a meta-analysis. Clin Oral Investig. 2021 Jan 29. doi: 10.1007/s00784-021-03807-w. Epub ahead of print. PMID: 33515120 ^{, 27} Kaur S, Bright R, Proudman SM, Bartold PM. Does periodontal treatment influence clinical and biochemical measures for rheumatoid arthritis? A systematic review and meta-analysis. Semin Arthritis Rheum. 2014 Oct;44(2):113-22. doi: 10.1016/j.semarthrit.2014.04.009. Epub 2014 Apr 28. PMID: 24880982 ^{, 28} Ortiz P, Bissada NF, Palomo L, et al. Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor necrosis factor inhibitors. J Periodontol. 2009;80(4):535-540. doi:10.1902/jop.2009.080447 PMID: 19335072

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