NYU Medical Grand Rounds Clinical Vignette Joseph Shin, MD Tuesday, April 3, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

57 year-old Hispanic woman with 6-7 years of worsening hand and wrist pain. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Usual state of good health until ~ 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.

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Allergies: NKDA Medications: Ibuprofen 400mg TID prn U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 ( ) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hand Xrays U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Wrist Xrays U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Moderately severe rheumatoid arthritis with evidence of erosive disease Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

After extensive counseling on options for additional medication, the patient agreed to start sulfasalazine, refusing injectable anti- TNF agents. Over several weeks, the patient’s sulfasalazine was titrated up with improvement in the patient’s symptoms. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Moderately severe rheumatoid arthritis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS