A 38-year-old woman is evaluated for joint pain and fatigue, which has been slowly progressive over the last year. Her other past medical problems include migraine headaches, lower back pain, and non-ulcer dyspepsia. She has had no miscarriages or thrombotic events.
Vital signs are within normal limits. Her body mass index is 30 kg/m². Examination shows symmetric tenderness of multiple small joints in the hands and a small effusion at the left knee.
X-ray image of the left hand is shown below.

Which of the following would have the most prognostic value for this patient?

Question

A 38-year-old woman is evaluated for joint pain and fatigue, which has been slowly progressive over the last year. Her other past medical problems include migraine headaches, lower back pain, and non-ulcer dyspepsia. She has had no miscarriages or thrombotic events.
Vital signs are within normal limits. Her body mass index is 30 kg/m². Examination shows symmetric tenderness of multiple small joints in the hands and a small effusion at the left knee.
X-ray image of the left hand is shown below.

Which of the following would have the most prognostic value for this patient?

Quizplus · Accepted Answer

11ec193a_993a_874b_853d_bb9d417809e6_MD0002_00 This patient's presentation suggests rheumatoid arthritis (RA). Patients typically complain of morning stiffness, often with associated systemic symptoms (eg, myalgia, fatigue, low-grade fever, weight loss). The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA require all of the following for diagnosis: Symptoms >6 weeksInflammatory arthritis >3 jointsPositive rheumatoid factor (RF) and/or anti-citrullinated peptide (anti-CCP)↑ C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)Exclusion of other similar conditions (eg, psoriatic arthritis, acute viral polyarthritis, polyarticular gout or calcium pyrophosphate deposition disease, systemic lupus erythematosus) Symptoms >6 weeks Inflammatory arthritis >3 joints Positive rheumatoid factor (RF) and/or anti-citrullinated peptide (anti-CCP) ↑ C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) Exclusion of other similar conditions (eg, psoriatic arthritis, acute viral polyarthritis, polyarticular gout or calcium pyrophosphate deposition disease, systemic lupus erythematosus) 11ec193a_993a_874c_853d_e5ef5ce144c5_MD0002_00 However, patients with seronegative, recent-onset, or inactive RA may not meet all these criteria. Early identification of predictive factors for erosive RA can lead to more aggressive therapy with disease-modifying agents to prevent irreversible injury. Radiographic erosions ("marginal erosion"), such as the left 3rd metacarpophalangeal joint in this patient (blue arrow), can suggest RA and indicate underlying erosive RA. These erosions eventually lead to joint inflammation and loss of joint space (red arrows). RF is positive in 70%-80% of RA patients. However, RF is also positive in 5%-10% of healthy individuals, 20%-30% of patients with systemic lupus erythematosus, and nearly all patients with mixed cryoglobulinemia. Anti-CCP antibodies have similar sensitivity to RF but are much more specific for RA (95%-98%). High titers can help with diagnosis and predict erosive RA. Elevated ESR and CRP can also predict poorer functional outcomes in RA and should also be checked during the diagnostic evaluation. (Choice B) This patient does not have typical features of systemic lupus erythematosus. Antinuclear antibodies would be nonspecific in this patient and would not influence prognosis. (Choice C) Anti-tissue transglutaminase antibodies are found in celiac sprue. Celiac disease can cause osteopenia and osteoporosis due to malabsorption. However, the marginal bony erosions and carpal crowding seen in this patient are not present in celiac disease. (Choice D) Fibromyalgia usually presents with muscular and soft-tissue pain instead of the predominant joint pain seen in this patient. This patient's active synovitis (small effusion of the left knee) and positive x-ray findings make inflammatory arthritis more likely. (Choice E) Elevated fasting transferrin saturation is helpful in diagnosing hereditary hemochromatosis. This diagnosis is unlikely in this relatively young woman. Squared-off bone ends and hook-like osteophytes in the second and third metacarpophalangeal joints are common findings in the arthropathy of hereditary hemochromatosis. Educational objective: Serologic factors for erosive rheumatoid arthritis can predict the need aggressive therapy to prevent irreversible injury. Factors such as anti-citrullinated peptide antibodies and/or joint erosions seen on x-ray are associated with poor prognosis and more aggressive disease. __________ References: Baseline anti-citrullinated peptide antibody (ACPA) titers and serum interleukin-6 (IL-6) levels possibly predict progression of bone destruction in early stages of rheumatoid arthritis (ERA). (http://www.ncbi.nlm.nih.gov/pubmed/22457007) Musculoskeletal manifestations in patients with thyroid disease. (http://www.ncbi.nlm.nih.gov/pubmed/12864792) Role of metacarpophalangeal joint anatomic factors in the distribution of synovitis and bone erosion in early rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/12746894)

A 38-Year-Old Woman Is Evaluated for Joint Pain and Fatigue