20100006005 SHORT CASE 2

 This is a case of a 45 year old female,resident of Nalgonda, technician by occupation came to the op with the chief complaints of 

1) C/O multiple joint pains and swellings since 15 years 

2) c/o generalised weakness and easy fatiguability since 6 months

History Of Presenting Illness:

Patient was born out of non consanguionus marriage and had 2 siblings . 

at 15 yrs of age - Got married in 10th class (Non consanguinous marriage) Her partner was a from rich family where he doesnt used to go to job and used to drink alchol through out the day . and used to come back to home by evening and started to physically and mentally abuse our patient.

AT 18 YEARS - She gave birth to a healthy first male child through LSCS(No significant medical history was given for indication of LSCS)

AT 20 YEARS- Gave birth to a healthy baby girl through LSCS

She used to be a  homemaker initially.

Due to her husband’s aggressive behaviour, she ingested pesticide which was seen by her sister.

immediately She was given some saltwater (which was home remedy to induce vomiting),induced vomitings and later she was shifted to Osmania hospital where she was admitted for 2 days and treated for ?organophosphorous poisoning.

Later she came away from her husband with her children for their education and  

20 YEARS BACK (JAN 2003)-She joined as a technician  in our hospital and also worked as a tailor 

17 YEARS BACK(in 2006)-

One fine day patient initially observed left ankle swelling and left leg edema which initially resolved overnight  but later didn’t seem to resolve with rest.

3-4 months later , she c/o bilateral lower limb edema about which she neglected due to her work stress

Gradually over a period of time , She also c/o pain in the large joints (ankle, knee, wrist ,elbow ,shoulder) and also neck pain .

There was no h/o small joint involvement 

She used homeopathy medication but the pain didn’t seem to resolve

7 YEARS BACK (2016)

From 2006 to 2016, these joint symptoms gradually progressed in severity, now also involving several large joints (shoulders, elbows, knees ,wrist , ankle, lower backache) warranting several medical consults, where she was frequently prescribed pain killers and other homeopathic medications. The patient did not have any documentation of the pain killers he took in these 8 years. He reported that his symptoms alleviated with these drugs but he intermittently had worsening of same symptoms in the interim. The patient denied any history of skin rash, photosensitivity, nasal or oral ulcers, chest pain or abdominal pain, weakness in his limbs (such as difficulty in taking stairs or lifting heavy stones and nor any weakness in his distal aspects of limbs such as mixing food, buttoning his shirt or holding a glass or slipping of footwear), isolated single joint pain or edema, or a past history of kidney stones.she also does not have any history of difficulty in swallowing, altered bowel habits, pain in the pulp of his digits, or painful tearing, photophobia or visual loss. she also denied any history of gritty sensation in eyes or dryness of mouth.

Visited this hospital due to severe pain in the joints, and diagnosed to be having 

anti CCP positive, ANA negative.

diagnosed with Rheumatoid arthritis and

She was started on Intraarticular triamcinolone and NSAIDs

During one of her routine checkups, she also c/o increase in her weight for which Thyroid profile is done and she was diagnosed with HYPOTHYROIDISM. She was kept on Tab. Thyronorm 25mcg PO/OD 

5 YEARS BACK (2018)

She was also kept on Tab.Wysolone 5mg PO/OD(used it for 3 years) and Tab.Methotrexate (15mg) PO/OD

4 YEARS BACK(2017)

She was also kept on Hydrochloroquine (used it till 2022)

Also on Tab.Sulphasalazine 1000mg

2 YEARS BACK 

Due to medication she c/o Recurrent epigastric pain and bloating like sensation where she underwent endoscopy  and diagnosed with gastric ulceration since then patient is on PPI's.(Tab Rabeprazole 40mg once daily)

AUGUST 2022

During one of her routine investigations she was diagnosed to be having Type2 Diabetes Melkite’s for which she was kept on Tab.Metformin 500mg PO/OD

Past History

No significant past history.

PERSONAL HISTORY 

DIET- Mixed

APETITE- Good 

BOWEL AND BLADDER MOVEMENTS -Regular

SLEEP -Adequate

ADDICTIONS -none 

MENSTRUAL HISTORY -

Age of Menarche -13 yrs

Periods -regular 5/28

No of pads-3/ days 

Pain and clots absent 

FAMILY HISTORY - No significant family history noted . 

Social & Educational History

Married for 18 years with 2 children. Secondary education upto Class 10th in Telugu medium.

Localisation of Chronic Problem

This 45 year old woman has a 15 year history of bilaterally symmetrical progressive inflammatory polyarthritis. Features favouring an inflammatory pathology are -

1. Features of inflammation such as severe pain associated with edema of the joints and limitation of range of active movements
2.  Early morning stiffness, lasting for more than 30 mins (for 1 hour in this patient)
3. Pain and edema of joints improving with activity and worsening with rest
4. Features of uncontrolled systemic inflammation such as fever, involuntary loss of weight associated with loss of appetite.
5. Swellings at joints and deformation of normal joint posture 

Provisional Diagnosis - Bilaterally Symmetric Chronic Progressive Inflammatory erosive Peripheral Polyarthritis

Clinical Examination

Initial examination revealed, the patient was conscious, coherent and co-operative, lying in bed in supine position. 

Vitals were taken in supine and sitting position - 

Supine Position

Pulse - 92 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay. All peripheral pulses were normal.

Blood Pressure - 140/90 mmHg

Temperature - 98.3F

Respiratory Rate - 24 cycles per minute. Mildly acidotic + (with prolonged duration of expiration)

Sitting Position

Pulse - 96 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay.

Blood Pressure - 140/90 mmHg

Head to Toe General Examination

Ht-155cm

Wt-74 kgs

General Condition - Fair built and appears well nourished.

Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp.

Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. sclera of both eyes normal. Palpebral conjunctival pallor +. No icterus. No cyanosis.

General Head, Neck & ENT - No abnormalities. No lymph node enlargement.

Axial - No apparent spinal deformities

Fingers and Nails - No clubbing or cyanosis. Capillary refill time - 2 seconds.

Bilateral pitting type pedal edema +, extending upto middle of legs.

SYSTEMIC EXAMINATION: 

MUSCULO SKELETAL SYSTEM:

Axial Skeleton

Inspection - No visibly apparent spinal deformities; 

Palpation - Inspectory findings confirmed. No spine tenderness. 

Movements - Atlanto-occipital - Flexion, extension and lateral flexion normal

                      Atlanto-axial - Rotation of head normal

                      Spinal Flexion, Spinal Extension, Lateral Flexion and Rotation are normal

Appendicular Skeleton - Upper Limbs (Positive Findings)

Shoulders (both sides) - 

       - Inspection - Attitude - Slightly flexed and internally rotated; Contour normal; No edema or erythema

       - Palpation - no increase in temperature on both sides

       - Range of Movements - No limitation of range of movements (flexion, extension, adduction, abduction, internal rotation and external rotation)

Elbows (both sides) -

        - Inspection - Attitude - mid-flexion;  alignment of elbow and forearm - normal; No Edema  ; No scars or sinuses; no muscle wasting

        - Palpation - All Inspectory findings are confirmed; No Raised temperature ; no Edema ; mild Wincing on touch + ; Fluctuation test negative ; 3 point bony relationship intact

        - Range of Movements - No limitation.

Wrists (both sides) - 

        - Inspection - Attitude - Mild extension; no Radial deviation of wrists ; no edema ; no Redness ;

        - Palpation - All Inspectory findings confirmed; no Temperature raise;  no Wincing on touch ; 

        - Range of Movements - No limitation.

Hands (both sides) - 

        - Inspection - Attitude - No Palmar subluxation and Ulnar deviation of the MCP joints; No Swollen and Erythematous PIP joints; No swelling or redness of DIP joints; No apparent muscle wasting; Mild hyper-extension of PIP of thumbs; Pulp of fingers normal

        - Palpation - All Inspectory findings are confirmed; No Temperature raise ; mild Wincing on palpation; Palpation of DIP joints is normal; 

        - Range of Movements - mild pain and mild limitation of active movements of flexion, extension and ulnar and radial deviation of MCP joints; mild pain and limitation of active and passive movements of flexion and extension at PIP joints. DIP joints normal.

Appendicular Skeleton - Lower Limbs (Positive Findings only)

Hip Joints (both sides)

        - No Limitation of passive movements of flexion and extension (towards the end of range of motion);

Knee Joints (both sides)

        - Inspection - Swelling and erythema + ; Attitude - flexion; 

        - Palpation - All Inspectory findings are confirmed;mild Raised temperature + ;

        - Range of movements - mild pain and limitation of active and passive movements of flexion and extension and lateral and medial rotation; 

Ankles (both sides)

         - Moderate pain and limitation of active and passive movements of plantar flexion and dorsiflexion; Mild pain and limitation of movements of inversion and eversion.

        - Palpation of Achilles tendon is normal.

Foot examination (both sides)

        - Mild pain and limitation of passive movements of flexion and extension of MTP joints; great toe flexion and extension normal;

Other Systems Examination

Cardiovascular System - No abnormalities detected

Respiratory System - No abnormalities detected

Abdominal Exam - No abnormalities detected

Nervous System - No deficits detected

INVESTIGATIONS 

CBP

Hb-9.8

TLC-8600

N/L/E/M/B-68/25/2/5/0

Platlets -4.5

MICROCYTIC HYPOCHROMIC ANAEMIA 

FBS-106

PLBS-241

HbA1c-7.0

THYROID PROFILE

T3-1.06

T4-12.03

TSH-4.15

LIPID PROFILE

Total cholesterol-190

Triglycerides-238

HDL-39

LDL-118

VLDL-47.6

RFT

Urea-24

Creatinine -0.7

Uric acid-2.2

Calcium-9.3

Phosphorus -3.1

Sodium-135

Potassium-4.6

Chloride-101

LFT

Total bilirubin-0.60

Direct bilirubin -0-15

SGOT-22

SGPT-17

ALP-173

Total proteins-5.8

Albumin -3.5

A/G ratio-1.58

Left knee lateral view showing decreased joint space and erosive changes are noted. 

Right knee lateral view

Right knee ap view

Left knee ap view decreased joint space with thinning of articular cartilage is seen

Right hand with wrist ap view

Left hand with wrist ap view

X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. scallop sign negative.

Left hand with wrist lateral view 

Right hand with wrist lateral view 

Left ankle lateral view 

Right ankle lateral view decreased joint space with erosive changes are noted. 

Left ankle ap view 

Right ankle ap view

ECG:

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

The patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis. Differential diagnosis for such conditions include - 

1. Rheumatoid Arthritis (most likely)
2. Rheumatoid Arthritis with coexistent Gout
3. Psoriatic Arthritis
4. Enteropathic Arthritis
5. Reactive Arthritis
6. SLE

With Rheumatoid Arthritis being most likely, ACR/EULAR classification criteria can be applied for diagnosis - 

This patient has >10 joints involved with multiple small joints involvement - 5 points; Symptom duration 10 years - 1 point; RA Factor - NEGATIVE; CRP elevated & ESR elevated- 1 point; Total Score - 7/10 

This patient had a chronic history of symmetric small joint and then large joint inflammatory peripheral polyarthritis, With minor erosions notable in the PIP and MCP joints of both hands, classification criteria are diagnostic for Rheumatoid Arthritis.

No history of skin rash (psoriatic arthritis) or chronically altered bowl habits (enteropathic arthritis); No history of dysuria or burning pain during micturition or a history of severe burning pain in eyes with photophobia and excessive tearing or discharge (reactive arthritis) makes the other diagnoses unlikely.

Epidemiologically, SLE occurs more commonly in females at a ratio of 9:1, coupled with this, the absence of other features of SLE, such as alopecia, photosensitivity rash, nasal or oral ulcers, serositis, hemolytic anemia etc. makes this diagnosis very unlikely.

The absence of muscle weakness, muscle pain and the presence of destructive arthritis makes Polymyositis / MCTD extremely unlikely (Polymyositis usually causes nonerosive arthritis).

FINAL DIAGNOSIS: 

45 YEAR OLD FEMALE WITH RHEUMATOID ARTHRITIS SINCE 15 YEARS WITH HYPOTHYROIDISM SINCE 7 YEARS AND DIABETES MELLITUS TYPE 2 SINCE 1 YEAR. 

Discussion: