NYU Medical Grand Rounds Clinical Vignette

Joseph Shin, MD

Tuesday, April 3, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•57 year-old Hispanic woman with 6-7 years of worsening hand and wrist pain.

Chief Complaint

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History of Present Illness

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DEPARTMENT OF VETERANS

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•Usual state of good health until ~2004-5

•New R ankle and L elbow pain

•Over 6-7 years, the pain progressed to involve bilateral wrists, hands and fingers, exacerbated by cold and repeated movement, but without tenderness, swelling or morning stiffness

•Self-treated with ibuprofen prn but with diminishing efficacy over the last several months.

Additional History•Past Medical History:

•Hypertension

•Past Surgical History:•Cesarean section x2

•Social History:•Never smoker. Denies alcohol or illicit drug use.•Immigrated from the Dominican Republic in 1989•Employed as a seamstress

•Family History:•No family history of autoimmune disease or inflammatory arthritis

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DEPARTMENT OF VETERANS

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Additional History

•Allergies: •NKDA

•Medications:•Ibuprofen 400mg TID prn

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DEPARTMENT OF VETERANS

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Physical Examination

•Obese, well-appearing woman

•Vital Signs:

• T:97.8F BP:130/70 HR:80 RR:16 and SaO2: 100% room air

•Bilateral wrists and R ankle with effusions and tenderness with decreased range of motion

•Tenderness in bilateral proximal interphalangeal joints

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DEPARTMENT OF VETERANS

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Laboratory Findings

•CBC•WBC 9900, Hg 10.6 g/dL, Plt 329,000•N 72%, L 20%, Monos 7%, Eos 1%

•Basic metabolic and hepatic panels: normal

•ESR 69 mm/hr (0-20)•CRP 52 mg/L (0.2-3.0)

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DEPARTMENT OF VETERANS

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Laboratory Findings

•Rheumatoid Factor: 792 IU/mL (<15)•Anti-CCP IgG Ab: >250 units (<20)•ANA positive (1:640)

•ds-DNA: <1 (negative)•SS-A/SS-B Ab <1.0 (negative)•RNP Ab >1.0 (negative)

•Hepatitis B sAg/sAb and HCV Ab: negative

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DEPARTMENT OF VETERANS

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Hand Xrays

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Wrist Xrays

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• Moderately severe rheumatoid arthritis with evidence of erosive disease

Working Diagnosis

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• The patient was started on prednisone 10mg daily, methotrexate 7.5mg weekly and folic acid 1mg daily.

• Over several weeks, the patient’s joint pain and swelling improved

• Prednisone was tapered down to 5mg every other day.

• Methotrexate was titrated up to goal dose of 20mg weekly.

Clinical Course

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DEPARTMENT OF VETERANS

AFFAIRS

• Over the following 6 months the patient reported resolution of all joint swelling and pain except in bilateral wrists resulting in

5-6/10 pain and difficulty with work as seamstress.

• Despite clinical improvement, inflammatory markers remained elevated

Clinical Course

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DEPARTMENT OF VETERANS

AFFAIRS

• After extensive counseling on options for additional medication, the patient agreed to start sulfasalazine, refusing injectable anti-TNF agents.

• Over several weeks, the patient’s sulfasalazine was titrated up with improvement in the patient’s symptoms.

Clinical Course

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DEPARTMENT OF VETERANS

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• Moderately severe rheumatoid arthritis

Final Diagnosis

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