1. NYU Medical Grand Rounds Clinical Vignette Monalyn R. Labitigan, M.D. PGY-3 November 17, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 28 year old woman presenting to the emergency department with joint pain for one year, worsening over one month. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in her usual state of health until one year prior to presentation, when she noted pain in her left shoulder. One month prior to presentation, her symptoms worsened to include pain in her shoulders, elbows, hands, wrists, and knees bilaterally, along with right hip pain and neck pain. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. At this time, the patient endorsed morning stiffness lasting three hours in all of her affected joints. She endorsed swelling and warmth of her hands and wrists as well. Her symptoms were mildly improved with ibuprofen and with movement, and were slightly worse at night and during cold weather. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: Denied Past Surgical History: Denied Social History: From Mexico, had been living in the United States for 6 years. She is a factory worker and uses her hands often. She stopped smoking cigarettes 6 years ago, drinks alcohol occasionally, and denied illicit drug use. She is currently not sexually active. Family History: Non-contributory Allergies: None Medications: Ibuprofen 400mg three times daily as needed for pain U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination General: Healthy-appearing young woman, in no apparent distress Vital Signs: T: 97.9 BP:98/60 HR:80 RR:12 and O2 sat:100% on room air U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination Musculoskeletal Exam: Tenderness to palpation of trapezius and lumbar paraspinal muscles bilaterally. Decreased rotational range of motion of the cervical spine. Tenderness to palpation of the shoulders bilaterally, left greater than right, with decreased range of motion in all directions. Bilateral wrist synovitis with decreased range of motion and ulnar deviation. Swelling of the metacarpophalangeal joints and proximal interphalangeal joints of both hands. The remainder of the physical exam was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: Hemoglobin 11, MCV 79 Remainder of CBC was within normal limits Basic Metabolic Panel: within normal limits Hepatic Panel: within normal limits Erythrocyte sedimentation rate: 34 (<20) C-reactive protein: 18 (0.215-3.0) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Symmetric inflammatory arthritis due to rheumatoid arthritis, versus systemic lupus erythematosus, psoriatic arthritis, or mixed connective tissue disease. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Interim History Additional laboratory studies were obtained which were notable for the following: ANA: positive 1:320, homogeneous pattern (<1:40) Rheumatoid Factor: 1050 (<15) Anti-citrullinated protein IgG: 179 (<20) Double-stranded DNA, anti-smith antibody, antibody to ribonucleoprotein, anti-Scl70, SS-A, and SS-B antibodies were all negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hand X-Ray U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Symmetric inflammatory arthritis due to rheumatoid arthritis. Revised Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. The patient was referred to the Bellevue Arthritis Clinic, where she was enrolled in the Grand Opportunity - Microbiome Center for Rheumatology and Autoimmunity (GO-MiCRA) study for Rheumatoid Arthritis. She completed one month of antibiotic treatment per study protocol. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. She is currently on weekly methotrexate therapy but has deferred concomitant treatment with oral steroids. She reports improvement in synovitis and morning stiffness, with decreases in both her erythrocyte sedimentation rate and C-reactive protein levels. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Seropositive, non-erosive rheumatoid arthritis, amenable to enrollment in the GO-MiCRA study. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS