A 32-year-old woman, an accountant, developed pain and swelling of the small joints of her hands and wrists six months ago. Her fingers were swollen in the morning, and she felt stiff all over for about two hours. Her right knee and both wrists were tender to the touch, warm, and slightly red. By mid-morning, the swelling and stiffness were gone. By 3:30 in the afternoon, however, she was exhausted and the balls of her feet ached. She had no previous illnesses. Two months ago she started taking two aspirin four times/day, after which she noticed that the swelling in her fingers, wrists, and knee had decreased and she had less pain in her feet. But she has lost five pounds over the past two months, has difficulty staying asleep at night, and has been feeling “down in the dumps.”

On physical exam she is afebrile, normotensive, and in no acute distress. The heart is normal size, has a regular rhythm, and there are no murmurs or rubs. The abdomen is soft and nontender, and there is neither hepatosplenomegaly nor palpable masses. On joint exam she has tenderness and swelling of both wrists, all MCPs and PIPs, her right knee, and all MTPs.

A. Acute inflammatory, monarticular arthritis, without systemic features
B. Acute intermittent, asymmetrical, inflammatory oligoarthritis
C. Chronic symmetrical, inflammatory polyarthritis, with systemic symptoms
D. Chronic noninflammatory monarthritis
E. Acute migratory, inflammatory polyarthritis
F. Chronic noninflammatory polyarthritis

A. Traumatic injury
B. Crystal-induced inflammation
C. Bacterial or viral infection
D. Immune-mediated inflammation

A. CBC and ESR or C-reactive protein (CRP)
B. Uric acid
C. RF and ANA
D. Lyme titer
E. BUN and creatinine
F. Complement levels (C3, C4, CH50)
G. Urinalysis
H. Liver enzymes

Laboratory test results were:  Hgb 10 gm%, WBC 8,000/mm³ with a normal differential, platelets 580,000/mm³, ESR 80 mm/hr, RF 240 IU, and ANA negative.  C3, C4, CH50, urinalysis, uric acid, calcium, phosphorus, BUN, creatinine, liver enzymes, creatine kinase, aldolase, and Lyme titer were all normal or negative.

A. Excisional biopsy of the nodule
B. Creatinine clearance
C. Bone scan
D. Arthrocentesis and synovial fluid analysis
E. EKG
F. Chest x-ray and pulmonary function tests
G. X-ray of hands, knees, and feet
H. No other diagnostic tests needed at this time

Question 5: Based on the clinical features identified in this patient, you would predict which of the following?

A. Progressive crippling to total disability
B. Spontaneous remission in two months
C. Complete remission in <two weeks, but recurrent episodes at increasing frequency over the next 20 years
D. Increasing severity over the next six months to two years, requiring increasingly potent medications
E. Low-grade disease with symptoms controllable with NSAIDs, and no progression to joint deformity

After working this case, the student should be able t

1. Describe four articular and four systemic features of rheumatoid arthritis.
   
   
2. List seven laboratory tests that should be ordered in evaluating a patient with undiagnosed inflammatory polyarthritis.
   
   
3. List four factors that correlate with a poor prognosis in RA.
   
   
4. List four diseases that produce symmetrical chronic polyarthritis.

Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-324.

Boers M. Rheumatoid arthritis; treatment of early disease. Rheum Dis Clin North Am 2001;27:405-414.

Harris ED Jr. Rheumatoid arthritis: pathophysiology and implications for therapy. N Engl J Med 1990;322:1277-1289.

Weyand CM, Goronzy JJ. Pathogenesis of rheumatoid arthritis. Med Clin North Am 1997;81:29-55.

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