Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Joseph Shin, MD
Tuesday, April 3, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•57 year-old Hispanic woman with 6-7 years
of worsening hand and wrist pain.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Allergies:
•NKDA
•Medications:
•Ibuprofen 400mg TID prn
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hand Xrays
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Wrist Xrays
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Moderately severe rheumatoid arthritis
with evidence of erosive disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• After extensive counseling on options for
additional medication, the patient agreed to
start sulfasalazine, refusing injectable antiTNF agents.
• Over several weeks, the patient’s
sulfasalazine was titrated up with
improvement in the patient’s symptoms.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Moderately severe rheumatoid arthritis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS