NYU Medical Grand Rounds Clinical Vignette

Sruthi Reddy, MD

PGY-2

10/9/12

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient is a 31 year-old pregnant woman with joint pain and swelling for one month.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• One month prior to presentation, the patient began to experience pain and bilateral swelling in her ankles, knees and hands.

• She described her pain as worse in the morning and associated with stiffness and difficulty walking – preventing her from performing simple tasks associated with daily living.

• Notably, she is G5P4 at eight weeks gestation.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

• Past Medical History: None

• Past Surgical History: None

• Social History: • Born in Guatemala

• Lives with her boyfriend and four healthy children

• Family History: None

• No known drug allergies • Medications:

• Calcium

• Vitamin D

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination• General: Well-appearing and in no acute distress• Vital Signs: T 96.6, BP 93/61, HR 79, RR 16, O2 sat 100% on room air• Right wrist warm, swollen and tender with full range of motion• Right 2nd and 3rd MCP and 2nd and 3rd PIP joints warm, swollen and tender• Left 2nd the 3rd PIP joins swollen and tender• Right knee warm, painful, with minimal effusion and with full range of motion• Left knee warm without effusion• Bilateral ankle swelling with decreased range of motion• Remainder of physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• CBC: Hb 10.3 g/dl, MCV 87• Remainder of CBC was within normal limits

• Basic Metabolic panel: within normal limits• Hepatic panel: within normal limits• Urine HCG: positive

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• Rheumatoid Factor 660 IU/mL (normal < 15 )• ESR 98 mm/hr (normal 0 – 20)• CRP 22.22 mg/L (normal < 3)• CCP IgG Ab: > 250 Units

( > 60 = strongly positive)• ANA Positive titer 1:160

Pattern homogenous• ds DNA Ab 7 (indeterminate) • Beta2 GP1 IgM Ab 29 U/mL (normal <10)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Imaging

Foot DX: hallux valgus of 1st MTP joints bilaterally, left greater than right.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Imaging

Cervical Spine Dx: multilevel ligamentous laxity

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Imaging

Hand Dx: possible small marginal erosion or subchondral cyst at the radial aspect of the base of the right 2nd proximal phalanx and at the right 2nd MCP.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Rheumatoid arthritis

• SLE

• Sjogren’s

• Mixed connective tissue disease

• Osteoarthritis

• Extrahepatic syndrome of viral or autoimmune hepatitis

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The recent onset of polyarticular synovitis, and presence of anemia, abnormal inflammatory markers and positive rheumatoid factor and CCP in the setting of a new pregnancy were consistent with the diagnosis of rheumatoid arthritis.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was started on prednisone as methotrexate and biologic therapies are contraindicated during pregnancy.

• The patient’s symptoms have improved and she is currently in the middle of a healthy pregnancy.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Rheumatoid Arthritis

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS