Hypersensitivity Patient A


At her yearly physical, a 46-year-old woman, who was working in an office of a large insurance company, reported that she had been feeling very tired for several months. She often had aching and stiff joints, and some joints are somewhat swollen. She is particularly stiff for several hours when she gets up in the morning or if she sits for longer than a fairly short time. She is taking sertraline and over-the-counter vitamin D. She does not use alcohol or tobacco. She is 5'3" and weights 135 lbs.


QUESTION: Does her history or medications suggest a possible cause of the fatigue?

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QUESTION: What is the common disorder that often causes prolonged morning stiffness and painful, stiff joints?

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QUESTION: Isn't she somewhat young for this disorder?

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QUESTION: Why didn't she come in to see her doctor earlier?

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On examination, the physician found that both wrists and some of the metacarpophalangeal and proximal interphalangeal joints on both hands were tender and slightly swollen. But they were not deformed. The knees had some pain, edema, and reduced range of motion. She was found to have an elevated C-reactive protein level of 25 mg/l (normal less than 10 mg/l). Rheumatoid factor was not detected. She was treated with ibuprofen. A month later, the hands and wrists were not changed much and the knees were worse. She was referred to a rheumatologist.



QUESTION: Why aren't the distal interphalangeal joints mentioned. (Distal here means closest to the ends of the fingers.)

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QUESTION: Is it significant that both sides of the body seem to be affected?

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QUESTION: What does the elevated C-reactive protein indicate?

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QUESTION: If she has rheumatoid arthritis, why wasn't rheumatoid factor detected?

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Six months later, the C-reactive protein level was 46 mg/l and rheumatoid factor was detected. Moreover, X-rays revealed a small amount of erosion of the heads of metacarpal bones. She also developed two painless, immobile, subcutaneous nodules at pressure points on her right elbow and one at a pressure point on her right wrist. Her medication was changed to weekly low dose methotrexate. This controlled the rheumatoid arthritis and a year later her joints were no worse.



QUESTION: She still had relatively mild rheumatoid arthritis when she was switched to methotrexate. Why did they take this significant step?

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QUESTION: Why are the nodules under the skin at pressure points mentioned, even though this has nothing to do with synovial joints?

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QUESTION: Here the methotrexate seems to be sufficent. But in cases where the methotrexate does not bring rheumatoid arthritis under control, what is often the next step?

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