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Medicine (Baltimore) 2014; 93:1.Chandran G, Ahern MJ, Seshadri P, Coghlan D. Chikungunya virus aches and pains: an emerging challenge. As an example, an ESR of 50 to 80 is not uncommon in patients with severely active RA. (See "Biologic markers in the diagnosis and assessment of rheumatoid arthritis", section on 'Anti-citrullinated peptide antibodies'.)Acute phase reactantsElevations of the ESR and/or CRP level are consistent with the presence of an inflammatory state, such as RA. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Additional research is needed to better characterize this population.Recent onset RA – Patients with disease for less than six weeks may be diagnosed with RA based upon findings otherwise characteristic of RA, including anti-CCP antibodies, if testing for viral serologies is negative and if other appropriate exclusions have been met. Peripheral blood leukocytosis with a left shift is common but not invariably present.A low threshold for suspecting infection is required, particularly in compromised hosts. Infrequently, nodules similar to those seen in RA may occur in patients with SLE, and other nodular lesions may mimic rheumatoid nodules. Clinical and immunopathologic features.

(See "Clinical manifestations and diagnosis of polymyalgia rheumatica".)Crystalline arthritisCrystalline arthritis (gout and pseudogout) can become chronic and even assume a polyarticular distribution. Decreased elastic fibers and the presence of myofibroblasts are noted in approximately 50 percent. Clinical and pathologic aspects of arthritis due to Ross River virus and other alphaviruses. Rubella virus and arthritis. The other two criteria were rheumatoid nodules and radiographic erosive changes typical of RA, but these are generally not present in the early stages of disease.Thus, while these criteria were very good at separating inflammatory from noninflammatory arthritis, the major drawback of the 1987 criteria has been their insensitivity in identifying some patients with early disease who subsequently develop typical established RA [10]. (See '2010 ACR/EULAR criteria' below.)The diagnosis of RA may also be made in some patients who do not meet all of our criteria. (See "Clinical manifestations of rheumatoid arthritis", section on 'Imaging'.)DIAGNOSISOur diagnostic criteriaThe diagnosis of rheumatoid arthritis (RA) can be made when the following clinical features are all present:Inflammatory arthritis involving three or more joints. Another test, anti-mutated citrullinated vimentin, gives similar results to anti-CCP and is used as an alternative in some laboratories [5]. If it is untreated or unresponsive to therapy, inflammation and joint destruction lead to loss of physical function, inability to carry out daily tasks of living, and difficulties in maintaining employment.Early recognition and treatment with disease-modifying antirheumatic drugs (DMARDs) is important in achieving control of disease and prevention of joint injury and disability.

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