CASE 112

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 60-year-old female with hand pain and stiffness.

 What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

Wrist joint: Periarticular osteopenia is seen. No erosions are evident in the radial or ulnar styloid. Scapholunate advance collapse is present more so in the left wrist.

FIRST CARPOMETACARPAL JOINT: Bilateral subluxation of the first metacarpal bone in relation to the trapezium joint bilaterally. A zigzag deformity of the thumb is noted Remaining carpometacarpal joints demonstrate severe periarticular osteopenia.

CARPOMETACARPAL JOINTS: Evidence of periarticular osteopenia is once again noted. Ulnar deviation is subluxation of the proximal phalanges in relation to the metacarpal heads is noted.

PIPs and DIPs: Diffuse osteopenia is seen. Swan-neck deformity of the second PIP is seen bilaterally.

DIAGNOSIS:

Advanced scapholunate collapse [SLAC wrist] with advanced rheumatoid arthritis changes seen in the hands bilaterally slightly worse on the left side.

PEARLS AND DISCUSSION:

Rheumatoid arthritis is a systemic inflammatory chronic disease which affects many organs by attacking the synovial tissue and the joints.

It has a more female predominance by 3-1 and usually affects patients in their 40s or 50s.

From a radiological perspective, it is important for you to know the diagnostic criteria for rheumatoid arthritis as developed by 2010 ACR-EULAR classification. Diagnosis requires a score 6 out of 10 for rheumatoid arthritis to be made.

A- Joint Involvement

·         0: Large Joint

·         1: 2-10 large joints

·         2: 1-3 small joints (with or without involvement of large joints)

·         3: 4-10 small joints (with or without involvement of large joints)

·         5: >10 joints (at least 1 small joint)

B- Serology

·         0: Negative RF and negative ACPA

·         2: Low-positive RF or low-positive ACPA

·         3: High-positive RF or high-positive ACPA

C- Acute Phase Reactants

·         0: Normal CRP and Normal ESR

·         1: Abnormal CRP and Abnormal ESR

D- Duration of Symptoms

·         0: <6 weeks

·         1: >6 week

Rheumatoid arthritis is a multisystem disease and extra skeletal involvement occurs late in the disease.

In the lungs, high-resolution CT will show ground glass disease along with interstitial pulmonary fibrosis UIP. Furthermore, BOOP can be seen. Bronchiectasis has been reported. Rheumatoid nodules in the lungs may cavitate. Caplan syndrome is seen when rheumatoid arthritis and pnemoconiosis occurs.

In the abdomen splenomegaly is part of Felty’s syndrome [splenomegaly, rheumatoid arthritis, and neutropenia.]

Treatment of rheumatoid arthritis is by lifestyle modification, steroids and nonsteroidal anti-inflammatory drugs as well as disease modifying antirheumatic drugs. Finally, anti-TNF treatments suppress the immunity and are known along with TNF antagonist as biological therapies.

FURTHER READING:

1.      Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum. Dis. Clin. North Am. 2001;27 (2): 269-81

2.      Sommer OJ, Kladosek A, Weiler V et-al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications. Radiographics. 25 (2): 381-98. 

3.      Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2003) ISBN:0323023282.