Rheumatoid Arthritis grand rounds

Grand Rounds Case Vignette: Rheumatoid Arthritis Ulrike K. Buchwald, M.D. November 29th, 2006 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. 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. 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 Preliminary Diagnosis Rheumatoid arthritis 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 Laboratory Data • Serology: RF: 1:64 Anti-cyclic citrullinated peptides antibodies: 1:128 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 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. 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 anticonceptive was prescribed. The patient responded well to treatment. Infliximab was discontinued after one year. Final Diagnosis Early erosive, seropositive rheumatoid arthritis