NYU Medical Grand Rounds Clinical Vignette

Monalyn R. Labitigan, M.D.

PGY-3

November 17, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient is a 28 year old woman presenting to the emergency department with joint pain for one year, worsening over one month.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient was in her usual state of health until one year prior to presentation, when she noted pain in her left shoulder.

•One month prior to presentation, her symptoms worsened to include pain in her shoulders, elbows, hands, wrists, and knees bilaterally, along with right hip pain and neck pain.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•At this time, the patient endorsed morning stiffness lasting three hours in all of her affected joints.

•She endorsed swelling and warmth of her hands and wrists as well.

•Her symptoms were mildly improved with ibuprofen and with movement, and were slightly worse at night and during cold weather.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Denied

•Past Surgical History:•Denied

•Social History:•From Mexico, had been living in the United States for 6 years. She is a factory worker and uses her hands often. She stopped smoking cigarettes 6 years ago, drinks alcohol occasionally, and denied illicit drug use. She is currently not sexually active.

•Family History:•Non-contributory

•Allergies: •None

Medications:•Ibuprofen 400mg three times daily as needed for pain

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: Healthy-appearing young woman, in no apparent distress

•Vital Signs: T: 97.9 BP:98/60 HR:80 RR:12 and

O2 sat:100% on room air

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination•Musculoskeletal Exam:

•Tenderness to palpation of trapezius and lumbar paraspinal muscles bilaterally. •Decreased rotational range of motion of the cervical spine.•Tenderness to palpation of the shoulders bilaterally, left greater than right, with decreased range of motion in all directions.•Bilateral wrist synovitis with decreased range of motion and ulnar deviation.•Swelling of the metacarpophalangeal joints and proximal interphalangeal joints of both hands.

•The remainder of the physical exam was within normal limits

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: Hemoglobin 11, MCV 79•Remainder of CBC was within normal limits

•Basic Metabolic Panel: within normal limits

•Hepatic Panel: within normal limits

•Erythrocyte sedimentation rate: 34 (<20)

•C-reactive protein: 18 (0.215-3.0)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Symmetric inflammatory arthritis due to rheumatoid arthritis, versus systemic lupus erythematosus, psoriatic arthritis, or mixed connective tissue disease.

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Interim History

•Additional laboratory studies were obtained which were notable for the following:

•ANA: positive 1:320, homogeneous pattern (<1:40)

•Rheumatoid Factor: 1050 (<15)

•Anti-citrullinated protein IgG: 179 (<20)

•Double-stranded DNA, anti-smith antibody, antibody to ribonucleoprotein, anti-Scl70, SS-A, and SS-B antibodies were all negative

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Hand X-Ray

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Symmetric inflammatory arthritis due to rheumatoid arthritis.

Revised Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was referred to the Bellevue Arthritis Clinic, where she was enrolled in the Grand Opportunity - Microbiome Center for Rheumatology and Autoimmunity (GO-MiCRA) study for Rheumatoid Arthritis.

• She completed one month of antibiotic treatment per study protocol.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• She is currently on weekly methotrexate therapy but has deferred concomitant treatment with oral steroids.

• She reports improvement in synovitis and morning stiffness, with decreases in both her erythrocyte sedimentation rate and C-reactive protein levels.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Seropositive, non-erosive rheumatoid arthritis, amenable to enrollment in the GO-MiCRA study.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS