CASE 127
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 47-year-old female with hand and foot pain.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
WRIST JOINT: Erosive changes of the distal radius with marked narrowing of the radiocarpal joint. Erosions of the ulnar styloid are appreciated.
CARPOMETACARPAL JOINTS: Marked narrowing of the first carpometacarpal joint with subluxation is seen bilaterally. Remaining carpometacarpal joints demonstrate periarticular osteopenia.
METACARPOPHALANGEAL JOINTS: Central erosive changes are present worse at the second and third metacarpophalangeal joints but also seen at the first metacarpophalangeal joint and fifth metacarpophalangeal joints bilaterally and almost symmetrically. Narrowing of these joints is also noted.
PIPs and DIPs: Zigzag deformity of the thumb is seen bilaterally. Severe narrowing of the PIPs and DIPs is now present bilaterally and almost symmetrically. Flexion deformity of the left PIP is noted.
The feet radiographs demonstrate periarticular and central erosions of the MTPs bilaterally with severe narrowing of the joint space as well as fibular deviation of first through fourth digits bilaterally. Central erosions are also seen in all digits 1-4.
Narrowing of the tarsometatarsal joint space 1 through 5 is seen bilaterally. Diffuse osteopenia noted in both ankle joints and feet bones.
DIFFERENTIAL DIAGNOSIS:
The differential diagnosis rheumatoid arthritis Versus psoriatic arthritis.
DIAGNOSIS:
Mutilating rheumatoid arthritis.
PEARLS AND DISCUSSION:
Arthritis mutilans: A generic term for end stage joint destruction accompanied by osteolysis, seen in advanced psoriaticarthritis, also in rheumatoid arthritis, mixed connective tissue disease.
There are different radiological classification systems for rheumatoid arthritis. The most often used system is the Larsen classification. The Larsen method includes both erosions and joint space narrowing as a single score, on a scale of 0 to 5 per reference radiographs (Table I).
0 Intact bony outlines and normal joint space.
1 Erosion less than 1 mm in diameter or joint space narrowing.
2 One or several small erosions, diameter more than 1 mm.
3 Marked erosions.
4 Severe erosions, where there is usually no joint space left, and the original bony outlines are partly preserved.
5 Mutilating changes, where the original bony outlines have been destroyed First-line and second-line drugs (disease-modifying antirheumatic drugs) are available for conservative treatment. The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate (Rheumatrex, Trexall), and hydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents. Third-line drugs, so called biologicals, are cytokine modulators. By targeting molecules involved in the inflammatory response, biologicals help to reduce or suppress inflammation, and reducing joint damage.
| Grade | Definition | Findings |
|---|---|---|
| 0 | No radiographic changes | Abnormalities not related to arthritis may be present. |
| 1 | Slight abnormality | Periarticular swelling, paraarticular demineralization, slight joint space narrowing. |
| 2 | Definite early abnormality | Definite presence of erosions except in weight-bearing joints, joint space narrowing. |
| 3 | Medium destructive abnormality | Definite presence of erosions in all types of joints, joint space narrowing |
| 4 | Severe destructive abnormality | Erosions, joint space narrowing, bone deformation in weight-bearing joints |
| 5 | Mutilating abnormality | Disappearance of the original articular forces, gross bone deformities in weight-bearing joints |
FURTHER READING:
1. Grainger A., McGonagle D.: Imaging in rheumatology, 2003, 15: 286-297.
2. Larsen A., Dale K., Eek M.: Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn, 1977, 18: 481-491.
3. Ravindran V., Rachapalli S.: An overview of commonly used radiographic scoring methods in rheumatoid arthritis clinical trials. Clin Rheumatol, 2011, 30: 1-6
