Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Sruthi Reddy, MD
PGY-2
10/9/12
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 31 year-old pregnant
woman with joint pain and swelling for one
month.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
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
• ESR
• CRP
• CCP IgG Ab:
660 IU/mL (normal < 15 )
98 mm/hr (normal 0 – 20)
22.22 mg/L (normal < 3)
> 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
Differential Diagnosis
•
•
•
•
•
•
Rheumatoid arthritis
SLE
Sjogren’s
Mixed connective tissue disease
Osteoarthritis
Extrahepatic syndrome of viral or
autoimmune hepatitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Rheumatoid Arthritis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS