1. NYU Medical Grand Rounds Clinical Vignette Sruthi Reddy, MD PGY-2 10/9/12 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 31 year-old pregnant woman with joint pain and swelling for one month. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. One month prior to presentation, the patient began to experience pain and bilateral swelling in her ankles, knees and hands. She described her pain as worse in the morning and associated with stiffness and difficulty walking – preventing her from performing simple tasks associated with daily living. Notably, she is G5P4 at eight weeks gestation. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: None Past Surgical History: None Social History: Born in Guatemala Lives with her boyfriend and four healthy children Family History: None No known drug allergies Medications: Calcium Vitamin D U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: Well-appearing and in no acute distress Vital Signs: T 96.6, BP 93/61, HR 79, RR 16, O2 sat 100% on room air Right wrist warm, swollen and tender with full range of motion Right 2 nd and 3 rd MCP and 2 nd and 3 rd PIP joints warm, swollen and tender Left 2 nd the 3 rd PIP joins swollen and tender Right knee warm, painful, with minimal effusion and with full range of motion Left knee warm without effusion Bilateral ankle swelling with decreased range of motion Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: Hb 10.3 g/dl, MCV 87 Remainder of CBC was within normal limits Basic Metabolic panel: within normal limits Hepatic panel: within normal limits Urine HCG: positive U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings Rheumatoid Factor660 IU/mL (normal < 15 ) ESR98 mm/hr (normal 0 – 20) CRP22.22 mg/L (normal < 3) CCP IgG Ab: > 250 Units ( > 60 = strongly positive) ANAPositive titer 1:160 Pattern homogenous ds DNA Ab7 (indeterminate) Beta2 GP1 IgM Ab29 U/mL (normal <10) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Imaging Foot DX: hallux valgus of 1st MTP joints bilaterally, left greater than right. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Imaging Cervical Spine Dx: multilevel ligamentous laxity U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Imaging Hand Dx: possible small marginal erosion or subchondral cyst at the radial aspect of the base of the right 2nd proximal phalanx and at the right 2nd MCP. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Rheumatoid arthritis SLE Sjogren’s Mixed connective tissue disease Osteoarthritis Extrahepatic syndrome of viral or autoimmune hepatitis Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. The recent onset of polyarticular synovitis, and presence of anemia, abnormal inflammatory markers and positive rheumatoid factor and CCP in the setting of a new pregnancy were consistent with the diagnosis of rheumatoid arthritis. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. The patient was started on prednisone as methotrexate and biologic therapies are contraindicated during pregnancy. The patient’s symptoms have improved and she is currently in the middle of a healthy pregnancy. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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