Medicine Grand Rounds Clinical Vignette
Claudine Portella, MD
• CC: A 35-year-old female complains of 6 weeks of swelling in her hands. • HPI: The patient was in her usual state of good health until 6 weeks prior to presentation when she developed morning stiffness in her right and left 3rd digit proximal interphalangeal joints. The morning stiffness lasts for a few hours and has impaired her activities of daily living. She also describes generalized fatigue. She denies ocular, pulmonary or cardiac complaints. She denies fevers or weight loss.
Past History
• Past Medical History: Denies • Meds: None • Social History: Recent immigration from Philippines. No sick contacts. No substance abuse. • Gyn History: monogamous relationship. No hx of sexually transmitted infections. No hx of HIV.
Physical Exam
• T: 99.6 HR: 80 BP: 120/78 RR: 14 • Joint Exam: Boggy-feel, Mild swelling and local tenderness with limitation of motion in bilateral PIP joints of 3rd digit. Reduced grip strength bilaterally.
Laboratory Findings
• Hematocrit= 32% MCV=90 Fl (80-100) • IgM rheumatoid factor titer= 1:160 (<1:20) • Anti-cyclic citrullinated peptide antibodies >40 units (<25 units)
Radiology
• Soft tissue swelling and early erosions in the proximal interphalangeal joints
Initial Diagnosis
• Rheumatoid Arthritis
Therapeutic Course
• She was prescribed ibuprofen 600 mg PO tid, prednisone 10 mg po daily, and physical therapy with minimal relief. • After 8 weeks, her swelling and morning stiffness worsened. A PPD was placed on her forearm and evaluated 48 hours later. It had 5 mm induration (normal: <15 mm). The patient was then treated with infliximab (Remicade®) and methotrexate. • She received infliximab infusions with a reduction of her symptoms. However after 10 weeks of treatment, she developed fever, weight loss and cough. • A chest radiograph revealed right upper lobe infilitrate. Her induced sputum stained positive for acid fast bacilli and a DNA probe confirmed Mycobacterium tuberculosis. Infliximab and methotrexate were discontinued and treatment for TB initiated.
Final Diagnosis
• Tuberculosis due to tumor necrosis factoralpha antagonist during the treatment of rheumatoid arthritis.
Clinical Question
• Which of the following statements regarding rheumatoid arthritis is true?
A. B. C. D. E. There is an association with the class II major histocompatibility complex allele HLA-B27. The earliest lesion in RA is an increase in the number of synovial lining cells with microvascular injury. Females are affected three times more often than are males, and this difference is maintained throughout life. African Americans most commonly have the class II major histocompatibility complex allele HLA-DR4. Titers of rheumatoid factor are not predictive of the severity of rheumatoid arthritis or its extraarticular manifestions.
Answer
Which of the following statements regarding rheumatoid arthritis is true? The earliest lesion in RA is an increase in the number of synovial lining cells with microvascular injury.