NYU Medicine Grand Rounds Clinical Vignette Natasha Berezovskaya, PGY-2 November 6, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

58 year old woman presents with progressive, generalized joint pain for the past 6 months Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The patient presented with pain in multiple joints, particularly of the metacarpophalangeal joints and bilateral elbows. She also had morning stiffness lasting approximately two hours. Her symptoms previously had been well managed on methotrexate and etanercept but due to social situations, had difficulty complying with this regimen this past year. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Rheumatoid arthritis Chronic renal insufficiency Hypertension Past Surgical History: Total left hip replacement Bilateral total knee replacement Social History Former Smoker Family History: Not on file Allergies: No known drug allergies Medications: Prednisone 2 mg daily, folic acid 1 mg daily, leucovorin 10 mg daily, diltiazem 240 mg daily, pantoprazole 40 mg daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Well-appearing Blood pressure:160/90, remainder of vitals were within normal limits Musculoskeletal: Reduced spinal movement with lateral bending and lordosis Bilateral shoulders with markedly reduced forward elevation and external rotation Flexion contractures at elbows Chronic deformities of wrists Left hip with diminished motion secondary to pain and slight tenderness at greater trochanter U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: within normal limits Basic Metabolic panel: BUN/Cr: 47/2.2 Remainder of basic was within normal limits Hepatic panel: within normal limits C-reactive protein: 20.2 (0-4.9 mg/L) Rheumatoid factor: 12.6 ( IU/ml) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Exacerbation of rheumatoid arthritis Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Medical Course Patient was restarted on methotrexate 5 mg twice a week and etanercept 50 mg every week with good effect

3 weeks prior to her clinic visit, the patient developed a productive cough and was placed on levofloxacin. Chest X-ray and CT revealed multiple small pulmonary nodules, most consistent with rheumatoid lung Methotrexate and etanercept were discontinued and patient was referred for further pulmonary workup at outside facility Medical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Labs were obtained during her clinic and were as follows: –CBC: Hgb: 10.0 (remainder was within normal limits) –BMP: BUN/Cr: 35/2.11 (remainder was within normal limits) – Quantiferon TB Gold: negative –C-reactive protein: 20.9 (0-4.9 mg/L) –Rheumatoid factor: 10.2 ( IU/ml) Medical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Following her clinic visit: –Patient developed bleeding in setting of immune thrombocytopenic purpura –She was treated with high-dose corticosteroids and rituximab. Platelet count normalized –The patient’s arthritic symptoms were under control following rituximab Medical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Rheumatoid Arthritis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS