A 45-year-old woman comes to the physician complaining of pain in her hands and wrists for the last 3 months. She says that her hands are "frozen" and tender every morning. She has no weight loss, fevers, chest pain, or back pain.
Examination of her joints shows mild swelling and tenderness of several proximal interphalangeal joints, metacarpophalangeal joints, and both wrists. There are no skin rashes or mucosal lesions. No lymph nodes are palpable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 45-year-old woman comes to the physician complaining of pain in her hands and wrists for the last 3 months.  She says that her hands are "frozen" and tender every morning.  She has no weight loss, fevers, chest pain, or back pain.
Examination of her joints shows mild swelling and tenderness of several proximal interphalangeal joints, metacarpophalangeal joints, and both wrists.  There are no skin rashes or mucosal lesions.  No lymph nodes are palpable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9939_c3f9_853d_67963f5a44a6_MD0002_00 This patient has characteristic features of rheumatoid arthritis (RA): chronic, symmetric polyarticular joint pain and stiffness; synovitis; and evidence of systemic inflammation. The diagnosis of RA is based primarily on clinical features - history and examination findings - with confirmation obtained from laboratory and radiologic testing. Elevated rheumatoid factor (RF) levels are detected in approximately 50% of patients at the time of diagnosis and in 75%-80% at some time during the course of the disease. Adding anti-cyclic citrullinated peptide (anti-CCP) antibody increases sensitivity (50%-75%) and specificity (>90%) of the initial assessment. Although RF and anti-CCP are typically positive in RA, many patients have "seronegative" RA (negative RF and anti-CCP), especially early in the disease. These patients generally have a somewhat less aggressive course. Other inflammatory markers that are useful in the diagnosis of RA (or in excluding similar conditions) include antinuclear antibody (ANA), C-reactive protein, and serology for viral hepatitis and parvovirus B19. X-rays of the hands and any other affected joints are also recommended to assess the aggressiveness of the disease and follow its course. (Choice A) Polymyalgia rheumatica (PMR) is a common inflammatory disorder characterized by subacute to acute muscle pain, most pronounced in the shoulder and hip areas. PMR is almost never seen in patients age <50 (this patient's age alone is nearly sufficient to exclude PMR), and localized synovitis is not a feature. (Choice B) The combination of conjunctivitis, urethritis, and spondyloarthropathy is termed reactive arthritis. HLA-B27 positivity is seen in >80% of patients with reactive arthritis. Reactive arthritis commonly presents with preceding genitourinary or gastrointestinal infection. (Choice D) Systemic lupus erythematosus is a chronic autoimmune disorder characterized by inflammation in widespread organ systems, especially skin, joints, kidneys, heart, and lungs. ANA is highly sensitive for the diagnosis (>95%), and anti double-stranded DNA antibodies are highly specific. (Choice E) Parvovirus B19 is a common infection in adults and children. Manifestations in adults are often nonspecific, although arthralgias are typical. Symptoms usually resolve quickly and rarely last for more than 6 weeks. Most adults in the general population have evidence of prior infection as indicated by a positive IgG titer, but IgM antibodies are more specific for acute infection. Educational objective: The diagnosis of rheumatoid arthritis (RA) is based primarily on clinical features with some support from laboratory and radiologic testing. Although rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) are typically positive in RA, many patients have "seronegative" RA (negative rheumatoid factor and anti-CCP), especially early in the disease. These patients generally have a somewhat less aggressive course. __________ References: Rheumatoid arthritis - early diagnosis and disease management. (http://www.ncbi.nlm.nih.gov/pubmed/23964304)

A 45-Year-Old Woman Comes to the Physician Complaining of Pain