NYU Medical Grand Rounds Clinical Vignette

1
NYU Medical Grand Rounds Clinical Vignette

• Sruthi Reddy, MD
• PGY-2
• 10/9/12

2
Chief Complaint

• The patient is a 31 year-old pregnant woman with
  joint pain and swelling for one month.

3
History of Present Illness

• One month prior to presentation, the patient
  began to experience pain and bilateral swelling
  in her ankles, knees and hands.
• She described her pain as worse in the morning
  and associated with stiffness and difficulty
  walking preventing her from performing simple
  tasks associated with daily living.
• Notably, she is G5P4 at eight weeks gestation.

4
Additional History

• Past Medical History None
• Past Surgical History None
• Social History
• Born in Guatemala
• Lives with her boyfriend and four healthy
  children
• Family History None
• No known drug allergies
• Medications
• Calcium
• Vitamin D

5
Physical Examination

• General Well-appearing and in no acute distress
• Vital Signs T 96.6, BP 93/61, HR 79, RR 16,
  O2 sat 100 on room air
• Right wrist warm, swollen and tender with full
  range of motion
• Right 2nd and 3rd MCP and 2nd and 3rd PIP joints
  warm, swollen and tender
• Left 2nd the 3rd PIP joins swollen and tender
• Right knee warm, painful, with minimal effusion
  and with full range of motion
• Left knee warm without effusion
• Bilateral ankle swelling with decreased range of
  motion
• Remainder of physical exam was normal

6
Laboratory Findings

• CBC Hb 10.3 g/dl, MCV 87
• Remainder of CBC was within normal limits
• Basic Metabolic panel within normal limits
• Hepatic panel within normal limits
• Urine HCG positive

7
Laboratory Findings

• Rheumatoid Factor 660 IU/mL (normal lt 15 )
• ESR 98 mm/hr (normal 0 20)
• CRP 22.22 mg/L (normal lt 3)
• CCP IgG Ab gt 250 Units
• ( gt 60 strongly positive)
• ANA Positive titer 1160 Pattern
  homogenous
• ds DNA Ab 7 (indeterminate)
• Beta2 GP1 IgM Ab 29 U/mL (normal lt10)

8
Imaging
Foot DX hallux valgus of 1st MTP joints
bilaterally, left greater than right.
9
Imaging
Cervical Spine Dx multilevel ligamentous laxity
10
Imaging
Hand Dx possible small marginal erosion or
subchondral cyst at the radial aspect of the base
of the right 2nd proximal phalanx and at the
right 2nd MCP.
11
Differential Diagnosis

• Rheumatoid arthritis
• SLE
• Sjogrens
• Mixed connective tissue disease
• Osteoarthritis
• Extrahepatic syndrome of viral or autoimmune
  hepatitis

12
Clinical Course

• The recent onset of polyarticular synovitis, and
  presence of anemia, abnormal inflammatory markers
  and positive rheumatoid factor and CCP in the
  setting of a new pregnancy were consistent with
  the diagnosis of rheumatoid arthritis.

13
Clinical Course

• The patient was started on prednisone as
  methotrexate and biologic therapies are
  contraindicated during pregnancy.
• The patients symptoms have improved and she is
  currently in the middle of a healthy pregnancy.

14
Final Diagnosis

• Rheumatoid Arthritis