Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Monalyn R. Labitigan, M.D.
PGY-3
November 17, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 28 year old woman presenting to
the emergency department with joint pain for one
year, worsening over one month.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
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
Working Diagnosis
Symmetric inflammatory arthritis due to
rheumatoid arthritis, versus systemic lupus
erythematosus, psoriatic arthritis, or mixed
connective tissue disease.
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
Revised Working Diagnosis
Symmetric inflammatory arthritis due to
rheumatoid arthritis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Seropositive, non-erosive rheumatoid arthritis,
amenable to enrollment in the GO-MiCRA study.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS