Grand Rounds Case Vignette: Rheumatoid Arthritis

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Grand Rounds Case VignetteRheumatoid Arthritis

• Ulrike K. Buchwald, M.D.
• November 29th, 2006

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• CC A 33 yo caucasian woman complains of malaise
  and pain in her wrists and hands for seven
  months.
• HPI The patient was in good health until seven
  months prior to presentation when she started to
  feel more fatigued, especially in the early
  afternoon. She developed pain in her
  elbows,wrists and the joints of her fingers,
  which was initially sporadic but then persisted
  for days. The pain was worse in the morning and
  after periods of rest. Tylenol or Ibuprofen would
  give relief for a couple of hours. At times her
  hands looked puffy and felt warm. She noticed
  that it took her more time in the morning to get
  up and dressed because of stiffness of her
  fingers which would last for about one hour. She
  also complained of a ten pound weight loss.

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Her symptoms had worsened over the last four to
six weeks and her PMD referred her to
a rheumatologist. The patient could not recall
having any rash in the recent year. She
denied having had any gastrointestinal or
genitourinary infection. She did not travel
recently outside of the New York area.
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Physical Exam

• Gen Tired appearing young female, in no acute
  distress
• Vitals T 99.7 HR 76 BP 115/70 RR 14
• HEENT pale conjunctivae
• Musculoskeletal
• wrists, metacarpophalangeal, proximal
  interphalangeal joints bilaterally swollen, warm,
  no erythema, tender to touch with compression
  pain, motion limited by pain, mild thenar atrophy
  

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Preliminary Diagnosis
Rheumatoid arthritis
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Laboratory Data

• - WBC 10.1 (4-12x109/l) Diff. count 76
  neutrophils, 18 lymphocytes, 5 monocytes
• - Hgb 10.6 (13.5-17.0 mg/dl), Hkt 32.8 (39-51)
• Platelets 448 (150-400 x 109/l)
• - Sodium 137 (137-145 mEq/l)
• - Potassium 4.2 (3.6-5.0 mEq/l)
• BUN 18 (10-24 mg/dl), Creatinine 0.9 (0.6-1.5
  mg/dl)
• - AST 35 (15-46 U/l), ALT 36 (8-50 U/l)
• Alk Phos 148 (39-117 U/l)
• Total protein 6.3 (6.3-8.2 mg/dl), Albumin 4.2
  (3.5-5.0 mg/dl)
• - Calcium 8.9 (8.3-10.3 mg/dl), Uric acid 5.5
  (2.5-7.5 mg/dl),
• - TSH 2.53 (0.5-4.0 mIU/l)
• - ESR 55 mm/h, CRP 18.2 mg/l
• - Urinalysis 5-10 RBC, 1 protein

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Laboratory Data

• Serology
• RF 164
• Anti-cyclic citrullinated peptides antibodies
  1128
• ANA negative
• C3 and C4 normal
• Hepatitis B/C serology negative
• Lyme IgM/IgG negative
• Parvovirus IgM/IgG negative
• Synovial fluid
• turbid, straw-colored
• 40,000 WBC/mm3, 85 neutrophils
• gram stain/culture negative
• no crystals seen

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Radiology
X-Ray of the hands showed soft-tissue swelling of
the metacarpophalangeal and proximal
interphalangeal joints. Symmetric joint space
narrowing and subtle erosions of the right 3rd
and right and left 4th metacarpophalangeal
joints.
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Therapeutic Course

• Combination therapy with methotrexate and
  infliximab was begun. The patient tested PPD
  negative prior to starting infliximab.
• In addition, folic acid and an oral
  anti-conceptive was prescribed.
• The patient responded well to treatment.
  Infliximab was discontinued after one year.

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Final Diagnosis

• Early erosive, seropositive rheumatoid arthritis