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RA with normal inflammatory markers and knee pain

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I was diagnosed with RA last October. All inflammatory markers were normal, but my anti-ccp was 154. The reason for the initial visit was knee pain. Since being diagnosed, I've had pain in almost every joint, but continue to have pain in right knee. The pain radiates all the way up the thigh and into right hip. Also have tingling sensations that run down the leg. Currently on -hidden- 50mg weekly injection. Because all my inflammatory markers are normal, my rheumatologist states she doesn't believe the knee pain is related to RA. I'm confused by this, because she told me at a previous appointment that it was. I have an appointment Wednesday for a cortisone injection. My question is, just because the CRP and SED rates are normal, why can this not be related to RA? I'm a RN in the ER and have seen many patients with obvious inflammation and their inflammatory markers are normal. So, then, why is it so inconceivable that I can have pain without the blood work to prove it? And if she doesn't believe it is because of my RA, what is my next step?

Category: Rheumatologist

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Category: Internal Medicine Specialist
 19 Doctors Online

Note : Your consult has been discussed by our Rheumatologist Dr. Bimlesh Pandey and Internist Dr. Deepu Sebastian. Since both of them have different view on your clinical diagnosis their consult replies are individually posted here. (Usually we consolidate the reply).

Consult Reply by Dr. Bimalesh Pandey, Consultant Rheumatologist
My diagnosis favours RA which is well controlled with Enbrel and DMARDS. The disease seems limited to knee joint with anti ccp positivity. In such cases were disease is limited to single large joint (especially knee) and is recurrent Synovectomy as a treatment option should be considered. It will eradicate local disease and will give histopathological specimen to rule in or out RA versus any other disease.
You should continue the RA therapy.
Hope this helps
Thank you.


Consult Reply by Dr. Deepu Sebastian, Consultant Internal Medicine Specialist.

In my opinion you seem not to have typical features of RA. (Probably not satisfying the 2010 Eular criteria for RA). You are right a normal CRP and SED do not rule out RA, but in that case other typical features are necessary for the diagnosis.
Two symptoms you have mentioned are particularly striking - The radiation of the pain and tingling. As you might know these are features suggestive of a possible neurological involvement. A symptom analysis is required in order to provide a more conclusive opinion. I would like to know about the following points.

1. Do you have pain in small joints of hands now ? If so how severe?
2. How many large joints are having the pain now ? Only knee and the hip ?
3. Since you have a knee pain radiating to hip via thigh, is it more like a leg pain ?
4. Do you have any swelling around any of the joints ?
5. Do you have any morning stiffness? (If so how long does it last? – 5mins, half hour, 1hour)
6. Do you have low back pain ?
7. Do you have pain in the upper limb joints ?
You can reply as a followup .
Thank you

Dr. Bimlesh Dhar Pandey
Category: Internal Medicine Specialist
Senior Residency: Rhematology, All India Institute of Medical Schiences, New Delhi, 2009
Post Graduate, Junior Residency: MD (Internal Medicine), Rajendra Institute of Medical Sciences, Jharkhand, 2006
Residency: Physiology, Institute of Medical Science, Banaras Hindu University, Varanasi, 2003
Internship: Government Medical College, Trichur, 2001
Medical School: MBBS, Calicut University, 2001
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