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Rheumatoid Arthritis

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Hello,

My wife (who does not speak English) was diagnosed by a local doctor as having rheumatoid arthritis. She is 30 years old, non-smoker, no children, and has no other medical conditions and does not currently use any medicine with the exception of Implanon hormonal birth control. Her sister, 38 years old, has been diagnosed by a specialist as having rheumatoid arthritis, and does suffer from a lot of pain. However, there do not appear to be any other family members in other generations affected by this disease. The doctor that diagnosed my wife was a general practitioner and did not do any specialized blood tests, so I don't know what he based his diagnosis on. Since then, we got X-rays of her hands and neck, as well as blood tests for her rheumatoid factor, antinuclear antibody, and C-reactive protein. We will upload both the X-rays and the blood tests.

Symptomatically speaking, my wife has occasional swelling of the knuckles of her hands with pain and numbness, somewhat more painful when clenching her fist. In the heels and the knees she has occasional swelling, and she sometimes feels cramps or tingling in her feet.

We would like to know if it is indeed rheumatoid arthritis, or if it could possibly be lupus or fibromyalgia, or something else like nerve problems or gout.

Please DO NOT POST THIS CASE ON ANY PUBLIC WEBSITES and please DO NOT SHARE THIS INFORMATION WITH THE GENERAL PUBLIC.

Thank you for your help.

Category: Rheumatologist

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Category: Internal Medicine Specialist
 19 Doctors Online

Hello,

Thank you for choosing DoctorSpring.

Rheumatoid Arthritis is clinical diagnosis which is backed by investigation. That means for an experienced MD it is possible to make a diagnosis in the clinic or bed side.

There are some missing diagnostic investigation. If it is possible (not a must) I would like to the results of following tests - ESR by wetergreen method, CRP ( c reactive protein), Thyroid function test, hepatitis b and c serology and anti-ccp. The reports you have uploaded is incomplete.

History wise she has high probability of Rheumatoid arthritis.
however we can't rule out Lupus, Sjogren syndrome and fibromyalgia with out the above mentioned investigations.

You can reply / upload files as a followup
Thank you


Patient replied :

Hello,

Thank you for the reply. I tried to upload the blood tests before, and I later emailed the tests to [email protected], but apparently they never reached you. So I am attaching them again. The tests include rheumatoid factor, antinuclear antibody, and C-reactive protein.

Thanks for your help.


Hello,

I had already gone through that test, I have asked a few more test than provided. 47 % of early arthritis may have all reports negative. This makes it very difficult to confirm early test.

So, how do we confirm? It is based on history and presentation which is quite suggestive in this case but not confirmatory of rheumatoid or Lupus or fibromyalgia.

I will request you to repeat ESR CRP again. Kindly get Thyroid function test, Vit D levels along with the test suggestive. We also do MRI of hand to diagnose this condition in very early disease.

I would suggest Thyroid function test, ESR CRP, Vit D estimation, and MRI in case of early RA.

Thanks
Bimlesh


Patient replied :

Hello Dr. Pandey,

I am sending you the results of some of the additional tests you requested. I also decided to have my wife get a uric acid test, just in case. I am typing out the results below, translated into English:

===================================
anti-CCP
Result: 1000 U (reference value: up to 20 U)

Thyroid
TSH: 0.51 ulUI/mL (reference value: 0.27 - 4.2 ulUI/mL)
free T4: 1.12 ng/dL (reference value: 0.93 - 1.70 ng/dL)
FT3: 3.47 pg/mL (reference value: 2.0 - 4.4 pg/mL)

Uric Acid
Result: 3.1 mg/dL (reference value: 2.4 - 5.7 mg/dL)

C-Reactive Protein
Result: 6.34 mg/L (reference value: <10 mg/L)

ESR by Westergreen
Result: 8 mm/H (reference value: 1 - 20 mm/H)
===================================

We did not so the vitamin D test yet, as it was very expensive. However, we can still get it if you think it is necessary.

I have not yet located an MRI lab yet, but if you think it is necessary I can keep looking.

So far, according to the reference values, the anti-CCP and Rheumatoid factor values are off the charts. What does this mean, and is it conclusive? Please include an approximate estimate of how much confidence you can give to the final diagnosis, or if there could still be other similar diseases that present similar symptoms. After making your diagnosis, could you please give us some information about ways to cope with the disease, including climate, diet, and lifestyle adjustments? Additionally, kindly give information about possible side effects of any treatments, and in your opinion if these side effects can be justified by the efficacy of the treatment. Please keep in mind that my wife is using Implanon (progestin-only birth control implant), and we need to be sure that any treatment method does not reduce the efficacy of the birth control.

Thank you in advance for your help.

Best regards,
Sam


Thank you Sam,

Upto 47% patients of early RA may have normal ESR and CRP.
CCP is very specific for Rheumatoid arthritis. Very high value of CCP is a poor marker and has poor prognostic implications. I do initiate treatment for Arthritis with above clinical and lab values but concurrent investigation like Contrast enhanced MRI of hand and wrist, makes it conclusive.

I would strongly recommend CEMRI hand with wrist at this stage.
Food, weather do not have any role. Smoking and alcohol is associated with poor outcome. The choice of drug is per availability and best local practice. The list of medicine and side effect can be discussed later, once we know the choice of medicine.

She can start methotrexate, hydroxychloroquine and small dose of steroids. These medicine do not lower the efficacy of progestin only pill.

Hope I have answered your queries, please feel free to discuss further.

Regards


Dr. Bimlesh Dhar Pandey
Category: Internal Medicine Specialist
Experience: 
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
Dr. Bimlesh Dhar Pandey and 4 other Medical Specialists are ready to help you

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