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Contributor: Jessica Berman, MD
A 20 year old female comes to see you because 4 months ago she began having pain and stiffness in the MCPs and wrists. The symptoms are worse in the morning lasting for 1 hour and improve with movement. There is fatigue but no other problems identified on review of systems. On exam the wrists are slightly swollen and tender and MCPs are tender but not swollen. ESR is 48. The rheumatoid factor (RF) is positive at 105 and the anti-cyclic citrullinated peptide (anti-CCP or ACPA) is >250. X-rays show peri-articular osteopenia but no erosions.
What is the significance of the tests ordered in making the diagnosis of RA?
What are the typical features seen in this patient that are helpful in making the diagnosis of RA?
This patient clinically has diffuse MCP and wrist synovitis which is indicative of RA. It is important to remember that RA is a clinical diagnosis. Other findings which support the diagnosis besides the presence of symmetrical small joint arthritis include the presence of osteopenia on x-ray and the high ESR. Since anti-CCP is highly specific for the disease it adds to the weight of the diagnosis. The presence of RF and anti-CCP put this patient at high risk for progression and should be considered when making treatment decisions.
A 58-year old woman was diagnosed with RA 15 years ago when she first presented with 16 tender and 12 swollen joints including the MCPs, PIPs, and wrists. At that time she was treated with hydroxychloroquine, sulfasalazine, and methotrexate without improvement. Past medical history is notable for HTN and a smoking history of 1ppd x 10 years.
On exam today, the patient shows the typical signs of RA with bilateral flexion deformities of the fingers and ulnar drift at the wrists. There is evidence of active synovitis in the left 2nd MCP only.
The following labs are obtained: ESR is 6 mm/hr, RF is positive at 105 and CCP is positive at >250. X-rays show multiple erosions in the MCPs and the wrists. The patient is currently on prednisone 15mg PO daily, methotrexate 20mg PO weekly and etanercept 50mg SQ weekly. The etanercept was added 6 months ago. The patient continues to have AM stiffness lasting longer than 2 hours and is unable to perform ADLs. The option for other treatments is discussed.
What are infection risks for this patient given the current therapy?
What does this patient need to know about their risk for heart disease and for the risk of malignancy?
(Answer questions 1 – 5 on a piece a paper. Find Answer Key at the bottom on the page.)
1. A 40-year woman comes in with 4 months of worsening joint pain and swelling of the small joints of the hands, wrists, feet and ankles, severe fatigue, and 2 hours of morning stiffness which improves as the day goes on and with movement. You obtain an x-ray of the hands and wrists that demonstrates diffuse osteopenia and marginal erosions in the MCPs and carpal bones of the wrist.
The test which has the greatest specificity for this patient’s diagnosis is:
2. A 50 year old with a long history of Rheumatoid Arthritis on methotrexate and etanercept calls to report 3 days of gradually worsening knee pain with swelling, difficulty bending the knee and trouble weight bearing. The knee appears red. All of the other joints that have been previously active are asymptomatic.
The next best management for this patient is:
3. A 35 year old with RA currently treated with methotrexate alone, previously with good control, comes in to see you with new and painful red right eye. On exam the eye is read with limbal sparing. The patient is sensitive to light and pressure on the globe produces pain.
Which of the following eye complications would most likely be seen in a patient with active Rheumatoid Arthritis?
4. You are seeing a 60-year-old patient with longstanding erosive RA, on methotrexate with a positive RF and CCP who comes in to see you because he noted several swellings on the extensor surface of the elbow. On exam, these appear to be flesh colored and are moveable, with a rubbery feel. They are nontender.
The histology which best represents the pathophysiology of these nodule is:
1) The correct answer is C.
CCP antibody is the most sensitive test for the diagnosis of RA with a sensitivity and specificity of greater than 98%. RF is much less specific and only about 60% sensitive. ANAs can be seen in RA in addition to lupus and other connective tissue disease so is not specific for the diagnosis. HLAB27 can be seen in association with seronegative arthritis. Double stranded DNA is specific for lupus and is not seen in RA.
2) The correct answer is B.
The next best step is to aspirate the joint to rule out infection, particularly since there is one joint out of proportion to the rest. Patients on immunosuppressive therapy sometimes fail to present with the common signs of infection (i.e., fever) and suspicion as such should be high. Aspiration is the only way to diagnose infection in this patient. X-rays and MRI may show an effusion but cannot definitively diagnose infection. Increasing methotrexate or adding steroids until infection is ruled out would be wrong.
3) The correct answer is B.
This patient has scleritis, which can be seen in up to 1% of RA patients. Uveitis is a more common problem in patients with seronegative arthritis such as spondyloarthritis or psoriatic arthritis. A cataract can be seen in patients with RA, particularly as a result of treatment with steroids, however it is not commonly due to the disease itself. Conjunctivitis is an infectious complication of the eye and would be due to immunosuppression, not the underlying disease.
4) The correct answer is A.
These are subcutaneous nodules, more common in more severe RA patients who, like this patient are seropositive for RF and/or CCP antibodies. Nodules may be a sign of more active disease. They can occur in 20-35% of patients. The most common location is on the extensor surfaces of the elbows. Methotrexate is thought to accelerate nodule formation in some patients.
On histology pallisading histiocyles can be seen. Septal panniculitis is seen with E nodousm. Crystals would be indicative of gout.
5) The correct answer is A.
All patients with RA should have an x-ray of the cervical spine prior to undergoing surgery to rule out instability. X-ray should be ordered with flexion and extension views to evaluate for atlanto-axial subluxation. Lumbar spine is not affected in RA so would not be indicated. PFTs would not be required unless there is a history of underlying lung disease. Dopplers wouldn’t be needed since RA patients are not necessarily thought to have increased hypercoaguable risk.
Last updated February 2015