NYU Medicine Grand Rounds Clinical Vignette

1
NYU Medicine Grand Rounds Clinical Vignette

• Natasha Berezovskaya, PGY-2
• November 6, 2013

2
Chief Complaint

• 58 year old woman presents with progressive,
  generalized joint pain for the past 6 months

3
History of Present Illness

• 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.

4
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

5
Physical Examination

• General Well-appearing
• Blood pressure160/90, 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

6
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 (0-13.9 IU/ml)

7
Working or Differential Diagnosis

• Exacerbation of rheumatoid arthritis

8
Medical Course

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

9
Medical Course

• 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

10
Medical Course

• 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 (0-13.9 IU/ml)

11
Medical Course

• 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 patients arthritic symptoms were under
  control following rituximab

12
Final Diagnosis

• Rheumatoid Arthritis