Rheumatoid ArthritisKatherine Nguyen, MD

Disclosures

• I have no disclosures

Case Presentation

Mrs. Cartilage is a 45 y/o F who presents to your office for pain and swelling of her fingers and wrists. She is otherwise healthy outside of pre-diabetes and HTN. She currently only takes amlodipine for her blood pressure and a multivitamin daily. She is a high school English teacher, and lives with her husband and two sons in San Diego.

Polyarthritis- history

• AM stiffness

• Small versus large joints

• Symmetrical distribution

• Duration >6weeks

• Family History

• Travel History

• Any associated symptoms

• Sick exposure

Case Presentation

On further history, she reports that pain has been present for >6 months. She denies any trauma, recent travel, or history of viral infections in the last year. She endorses pain mainly in her bilateral fingers and wrists, as she points to her MCPs and PIPs, which is worse in the morning and associated with ~60 minutes of stiffness. Outside of her joint findings, she mainly complains of increased fatigue and mild myalgias.

Differential Diagnoses

• RA

• CTD

• Viral (parvovirus, EBV, hepatitis, HIV)

• Crystalline arthropathy

• Metabolic

Polyarthritis- Physical examination

• Pattern/ distribution

• Alignment

• Warmth, tenderness, effusion, bogginess, bony swelling

• MCPS, wrists, PIPs

• DIPS

• Axial

• Compression neuropathy

Joint distribution in OA and RA

RA-Cutaneous manifestations

Rheumatoid Nodules

Tilstra JS, et al. Dermatol Clin. 2015 Jul;33(3):361-71.

Nontender

Found in 35% of RA patients

Correlated with RF positivity

Location: olecranon, olecranon bursa, proximal ulna,

fingers, Achilles or extensor tendons, sacrum or occiput

Exam: mobile, subcutaneous, rubbery OR adherent to

periosteum and hard

Differential Dx: tophi, rheumatic fever, xanthomas,

sarcoidosis, leprosy, granuloma annulare, multicentric

reticulohistiocytosis, methotrexate

Cutaneous manifestations in other rheumatic diseases

Case Presentation

Her vital signs in clinic are: T 98.6, HR 70, BP 127/82, BMI 25

On physical exam you notice symmetrical swelling of the bilateral MCPs and PCPs that are tender to palpation. The dorsum of the hand seems to be edematous. There is no redness and appreciable warmth of the joints affected. Range of motion of her bilateral fingers is restricted and you perceive decreased grip strength on exam. Both wrists have mild swelling and tenderness to palpation with slight reduction in wrist extension. The rest of her physical exam is normal.

Diagnostic tests- Laboratory studies

• CBC, CMP

• ESR, CRP

• RF

• CCP

• ANA (DSDNA, Sm, SSA, SSB, SCL-70)

• Uric acid

• Quant Gold, Hepatitis B,C

• Infectious serologies (Parvovirus, HIV, cocci, Lyme)

• ANCA

Radiographic studies

• Xrays• Soft tissue swelling• Periarticular osteopenia• Erosions• Joint space narrowing• Subluxation• ILD, fibrosis

• MRIs

• MSK ultrasound• Power doppler • Erosions

Case Presentation

You order an Xray of her hands and wrists which show some mild soft tissues swelling of the fingers and wrists and periarticular osteopenia. Labs revealed:

• ESR- 50

• WBC: 6, Hgb: 11, PLT: 370

• Na 137, K 4.1, Cl 98, Bicarb 24, BUN 10, Cr 0.7, Glu 100

• Rheumatoid Factor: 60 IU/mL (elevated)

• CCP Ab: 60 EU/ml (elevated)

RA

• Female:male 2-3:1

• 1% of worldwide/ 3% in native Indians

• Age 40-60 yrs

• Poor Prognostic factors:• RF, CCP• Extra-articular manifestations• Early erosions• High HAQ score• Persistently elevated ESR and CRP• >13-20 joints involved• Education/socioeconomic background

RA- treatment

• Nsaid

• Prednisone

• DMARDS • HCQ, MTX, Leflunomide, Sulfasalazine

• Biologics• Anti-TNF

• Selective costimulation modulators (Abatacept)

• Jak-inhibitors

• Anti-IL6R

• Anti-B cells (Rituximab)

• Anti-IL1R

Case Presentation

Mrs. Cartilage was started on Methotrexate adjunctive NSAIDs for her arthritis. She returns 4 months later for follow up and she reports of increasing pain of her bilateral wrists and duration of morning stiffness. Her pain is now affecting her ability to perform her ADLS, including cooking, typing and dressing herself. Her increased symptoms are also consistent with her exam as you see worsening swelling and tenderness of her bilateral MCPs and PCPs.

RA- treatment

• Treat to target

• Early treatment = better outcome

• Combination therapy

• Biologic therapy

• Goal: low disease activity or remission with DMARD(s)

• Using clinical tools to follow disease activity (CDAI, RAPID3, MDHAQ, etc)

Co-management by PMD

• DMARDs toxicities

• Cardiovascular risks

• Immunizations

• Pre-op clearance

Swollen Hands in Rheumatoid Arthritis

Images courtesy of J. Cush, MD

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