A 38-year-old man comes to the office for evaluation of bilateral progressive hand pain with intermittent swelling over the past 6 months. The patient has no other symptoms or history of trauma or family history of arthropathy. Medical history is significant for type 2 diabetes mellitus, for which he takes metformin. Vital signs are normal. BMI is 24 kg/m². Examination reveals mild swelling and tenderness over the second and third metacarpophalangeal (MCP) joints bilaterally. There is no muscle weakness. X-ray reveals joint space narrowing and chondrocalcinosis involving the second MCP joints with osteophyte formation at the second and third metacarpal heads. Serum alanine and aspartate aminotransferases are elevated. Which of the following therapies would be of most benefit to this patient?

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Explanation: 11ec25c8_d307_71d2_bc81_752d7f4aee00_MD0003_00 This patient has chronic arthritis with joint space narrowing similar to osteoarthritis (OA), but several features suggest hereditary hemochromatosis (HH) arthropathy, including: Onset at age <40 versus >40 with OA Predilection for the second and third metacarpophalangeal (MCP) joints and wrists versus distal interphalangeal joints and thumb bases with OA Presence of chondrocalcinosis (ie, cartilage calcification) HH is also suggested by comorbid diabetes, which is due to pancreatic iron deposition and is otherwise unusual in nonobese patients at this age. Elevated liver transaminases also suggest HH and make primary joint disorders less likely. In addition to the hand and wrist, other joints (eg, hips, knees) can be affected by HH arthropathy; characteristic x-ray findings include periarticular bony enlargement and subchondral lucency. Joint examination typically shows no signs of synovitis (eg, erythema, warmth), but acute inflammatory flares may occasionally occur. Arthropathy typically becomes apparent early in the course of HH and may be the presenting feature, although later presentations are possible. Management of HH arthropathy is primarily focused on symptom relief. Simple oral analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) are usually used first. However, patients benefit most from therapeutic phlebotomy, which is necessary to prevent further joint injury (with limited effect on the established arthropathy) and minimize the systemic complications of HH (eg, liver disease). (Choices A, B, and D) Rheumatoid arthritis (RA) is typically treated initially with NSAIDs or systemic glucocorticoids (eg, prednisone) to provide acute symptom relief. Thereafter, disease-modifying antirheumatic drugs are initiated for long-term management; methotrexate is commonly recommended, with tumor necrosis factor inhibitors (eg, etanercept) and other biologic agents used for patients with refractory symptoms. Although RA commonly causes joint space narrowing in the MCP joints, x-ray typically shows periarticular osteopenia and bony erosions rather than the chondrocalcinosis and osteophytes seen with HH. Educational objective: Hereditary hemochromatosis (HH) arthropathy often resembles osteoarthritis but differs in age at onset (<40); predilection for the second and third metacarpophalangeal joints and wrists; and presence of chondrocalcinosis. Management is primarily symptomatic (eg, acetaminophen, nonsteroidal anti-inflammatory drugs), but therapeutic phlebotomy is necessary to minimize other systemic complications of HH (eg, liver disease).

A 38-Year-Old Man Comes to the Office for Evaluation of Bilateral