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A 38-year-old woman presents with a 4-month history of symmetric, bilateral pain and stiffness in the wrists, MCPs and PIPs of her hands. Morning stiffness lasts more than 2 hours and improves with activity. The DIP joints are spared. She has fatigue and two small rheumatoid nodules over the right olecranon. On examination there are boggy synovial effusions of the wrists, second and third MCPs and second and third PIPs bilaterally. The metacarpophalangeal squeeze test is positive. Investigations: anti-CCP positive (high titre), RF positive at 1:160, ESR 72 mm/h, CRP 48 mg/L, Hb 105 g/L (microcytic), platelets 480 × 10^9/L. Hand X-rays show periarticular osteopenia and marginal erosions at the second and third MCP heads.
Questions
a) State the diagnosis, the classification criteria used and the score (4 marks).
Diagnosis: seropositive, active rheumatoid arthritis. Classification: the 2010 ACR/EULAR criteria — apply to a patient with at least one swollen joint not better explained by another disease; a score of 6 or more out of 10 classifies RA. Score in this patient:
- Joint involvement — second to tenth small joints (MCPs, PIPs, wrists) of both hands ⇒ 5 points (more than 10 small joints).
- Serology — high-positive anti-CCP and RF ⇒ 3 points.
- Acute-phase — abnormal ESR and CRP ⇒ 1 point.
- Duration — symptoms more than 6 weeks ⇒ 1 point.
Total = 10/10 → definite rheumatoid arthritis.[1]
b) Outline the initial pharmacological management with drug, dose, route, monitoring and counselling (4 marks).
- Methotrexate (anchor first-line DMARD): 7.5–25 mg ONCE WEEKLY orally (or subcutaneously), titrated to response; co-prescribe folic acid 5 mg weekly.
- Bridge with a short course of glucocorticoid — oral prednisolone 5–10 mg daily or IM methylprednisolone 80–120 mg — tapering as the DMARD takes effect.
- NSAID (e.g., naproxen 500 mg BD) with a PPI for symptomatic relief, shortest duration.
- Monitoring: baseline and serial CBC, LFT, U&E (every 2–4 weeks for 3 months, then monthly, then 2–3-monthly); assess disease activity at each visit using the DAS28 and treat to a target of remission (DAS28 below 2.6) or low disease activity, escalating every 3–6 months.
- Counselling: methotrexate is teratogenic — stop 3 months before conception (both partners); limit alcohol; report new dry cough or dyspnoea (pneumonitis); vaccinate before immunosuppression.
c) List four complications of long-standing seropositive rheumatoid arthritis and a specific bedside or investigation-based screening for each (2 marks).
- Atlantoaxial subluxation — lateral flexion-extension cervical spine X-ray before any anaesthesia; atlantodens interval over 3 mm is abnormal.
- Cardiovascular disease (leading cause of death) — annual CV risk assessment with a 1.5× multiplier; lipids, blood pressure, ECG.
- Interstitial lung disease (UIP) — high-resolution CT chest and lung function tests if new dyspnoea or crackles.
- Secondary (AA) amyloidosis — urine dipstick for proteinuria (nephrotic range) and serum creatinine; confirm with biopsy showing apple-green Congo-red birefringence.
(Other acceptable: Felty syndrome — CBC for neutropenia and abdominal exam for splenomegaly; scleritis — ophthalmology review; osteoporosis — DEXA scan; Sjögren — Schirmer test.)
References1ShowHide
- [1]Neogi T, Aletaha D, Silman AJ, et al. The 2010 ACR/EULAR classification criteria for rheumatoid arthritis. Arthritis and Rheumatism, 2010.PMID 20872596