NYU Medicine Grand Rounds Clinical Vignette

1. NYU Medicine Grand Rounds Clinical Vignette Natasha Berezovskaya, PGY-2 November 6, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 58 year old woman presents with progressive, generalized joint pain for the past 6 months

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Well-appearing • Blood pressure:160/90, 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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 patient’s arthritic symptoms were under control following rituximab

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Rheumatoid Arthritis