A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the meta-carpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?
The clinical picture of symmetrical swelling and tenderness of the metacarpophalangeal (MCP) and wrist joints lasting longer than 6 weeks strongly suggests rheumatoid arthritis (RA). Rheumatoid factor, an immunoglobulin directed against the Fc portion of IgG, is positive in about two-thirds of cases and may be present early in the disease. The history of lethargy or fatigue is a common prodrome of RA. The inflammatory joint changes on examination are not consistent with chronic fatigue syndrome; furthermore, patients with CFS typically report fatigue existing for many years. The MCP-wrist distribution of joint symptoms makes osteoarthritis very unlikely. The x-ray changes described are characteristic of RA, but would occur later in the course of the disease. Although arthritis can occasionally be a manifestation of hematologic malignancies and, rarely, other malignancies, the only indicated screening would be a complete history and physical examination along with a CBC.
A 70-year-old man complains of fever and pain in his left knee. Several days previously, he suffered an abrasion of his knee while working in his garage. The knee is red, warm, and swollen. An arthrocentesis is performed, which shows 200,000 leukocytes/µL and a glucose of 20 mg/dL. No crystals are noted. Which of the following is the most important next step?
The clinical and laboratory picture suggests an acute septic arthritis. The most important first step is to determine the etiologic agent of the infection. Staphylococcus aureus is the most likely agent in this setting, and antibiotics with potent anti-Staph effect are usually started empirically while awaiting the culture results. Synovial leukocyte counts in gout typically range between 2000/µL and 50,000/µL; in addition, serum uric acid levels are often normal in acute gout. In the absence of negatively birefringent crystals in the synovial fluid, a uric acid level will not be helpful. There are no symptoms suggesting connective tissue disease. Gonococci can cause a septic arthritis, but a urethral culture in the absence of urethral discharge would not be helpful. Antineutrophil cytoplasmic antibodies are present in certain vasculitides. There is no indication of systemic vasculitis in this patient.
A 60-year-old woman complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On examination, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. Which of the following is the best next step in evaluation?
The complaints described are characteristic of Sjögren syndrome, an autoimmune disease with presenting symptoms of dry eyes and dry mouth. The disease is caused by lymphocytic infiltration and destruction of lacrimal and salivary glands. The Schirmer test, which assesses tear production by measuring the amount of wetness on a piece of filter paper placed in the lower eyelid for 5 minutes, is the appropriate screening test. Most patients with Sjögren syndrome produce autoantibodies, particularly anti-Ro (SSA). Lip biopsy is needed only to evaluate uncertain cases, such as when dry mouth occurs without dry eye symptoms. Mumps can cause bilateral parotitis, but would not explain the patient’s complaint of a gritty sensation, which is the most typical symptom of dry eye syndrome. Corticosteroids are reserved for severe vasculitis or other serious complications. Although anxiety (for which a benzodiazepine could be administered) can cause a dry mouth, it would not cause either parotid swelling or dry eyes.
A 40-year-old man complains of acute onset of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension. On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities. Which of the following is the best next step in management?
The sudden onset and severity of this monoarticular arthritis suggests acute gouty arthritis, especially in a patient on diuretic therapy. However, an arthrocentesis is indicated in the first episode to document gout by demonstrating needle-shaped, negatively birefringent crystals and to rule out other diagnoses such as infection. The level of serum uric acid during an episode of acute gouty arthritis may actually fall. Therefore, a normal serum uric acid does not exclude a diagnosis of gout. For most patients with acute gout, NSAIDs are the treatment of choice. Colchicine is also effective but causes nausea and diarrhea. Systemic corticosteroids can be used if NSAIDs are contraindicated. Antibiotics should not be started for suspected septic arthritis before an arthrocentesis is performed. Treatment for hyperuricemia should not be initiated in the setting of an acute attack of gouty arthritis. Long-term goals of management are to control hyperuricemia, prevent further attacks, and prevent joint damage. Long-term prophylaxis with allopurinol is considered for repeated attacks of acute arthritis, urolithiasis, or formation of tophaceous deposits. X-ray of the ankle would likely be inconclusive in this patient with no trauma history. In addition, the x-ray changes of tophaceous gout take years to develop. In the absence of trauma, there is no indication for immobilization.
A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?
The patient has more than four of the required signs or symptoms of RA, including morning stiffness, swelling of the wrist or MCP, simultaneous swelling of joints on both sides of body, subcutaneous nodules, and positive rheumatoid factor. Subcutaneous nodules and anti-CCP antibodies are poor prognostic signs for the activity of the disease, and disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, antimalarials, sulfasalazine, leflunomide, antiTNF agents, or a combination of these drugs should be instituted. Methotrexate has emerged as a cornerstone of most disease-modifying regimens, to which other agents are often added. Low-dose corticosteroids (eg, prednisone 7.5 mg a day or less) have recently been shown to reduce the progression of bony erosions and, although controversial, are useful additions to DMARD therapy. High-dose steroids, however, should be avoided. Use of anti-inflammatory doses of both aspirin and nonsteroidals together is not desirable because it will increase the risk of side effects. Given the aggressive nature of this woman’s rheumatoid arthritis and negative prognostic signs, use of DMARDs is indicated. Significant joint damage has been shown by MRI to occur quite early in the course of disease.
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