Case for discussion: February 2017

A 26-year-old female presented to the clinic with a 4-year history of arthritis. She had symmetric pain in the joints involving the hands, wrists, elbows, shoulders, hip, knees, ankles and feet. Hand joints were the first to be involved. The pain was additive and relapsing. She had swelling in both the hands, wrists and feet. The patient experienced severe early morning stiffness for 1-2 hours. The pain aggravated with work and cold. She had severe backache involving the mid area for the past four years, and had difficulty in moving the neck and the mid back. Her previous laboratory investigations revealed: hemoglobin: 8.6 gm/dL, total WBC count: 7500 cells/cumm, neutrophils: 73%, lymphocytes: 20%, eosinophils: 5%, monocytes: 2%, platelet count: 3.37.000/ml, SGOT: 30, SGPT: 41, RF: 1, CRP: 10, serum uric acid: 5.9 mg/dL, and ASLO: negative.

The patient history also reported generalized weakness, weight loss, normal menstrual cycle and dry mouth. The systemic examination including cardiovascular, respiratory, per abdomen and central nervous system was unremarkable. The patient was on non-vegetarian diet, had normal appetite and sound sleep. Her BP was 120/60 mm/hg.

The patient was moderately built and nourished. Her physical examination revealed tenderness and swelling on both wrists, elbows, shoulders, feet, ankles, knees and subtalars. The patient was on methotrexate 25 mg injection, iron syrup, folic acid 5 mg, hydroxychloroquine 200 mg, calcium + vitamin D3 500 mg, pantoprazole 40 mg, etoricoxib 60 mg and ranitidine 150 mg. The results of clinical and laboratory investigations during the first and second visit are given in table 1.

Table 1: Results of clinical and lab investigations done during current consultation

Parameters evaluated

Results

First visit

Second visit

Hemoglobin (gm/dL)

9.5

-

Total WBC count (cells/cumm)

9380

-

Neutrophils (%)

69.8

-

Basophils (%)

0.2

-

Lymphocytes (%)

23.5

-

Eosinophils (%)

0.2

-

Monocytes (%)

6.3

-

ESR (Westergren method) (mm/hour)

124

-

Platelet count (lakh/ cu.mm)

4.49

-

RBC count (g/dL)

4.2

-

Random blood sugar (mg/dL)

102

-

S.G.O.T [A.S.T] (IU)

19

-

S.G.P.T [A.L.T] (IU)

17

-

Creatinine (Kinetic Jaffe) (mg/dL)

0.7

-

ANA immunofluorescence (1:40 dilution)

Positive,3+ homogenous pattern

-

CRP-NEPH

75.70

-

RF-Nephelometry

7980.0

-

Hepatitis b surface antigen (HBsAg) by CLIA (rapid)

Non-reactive

-

Hepatitis'c' virus antibody (rapid)

Non-reactive

-

Total bilirubin (Modified Jendrassik)

0.5

-

Direct bilirubin (Modified Jendrassik)

0.2

-

Indirect bilirubin

0.3

-

Alkaline phosphatase (Kinetic) (IU/L)

69

-

Gamma GT

18

-

Total protein (g/dL)

8.2

-

Serum albumin (g/dL)

3.8

-

Globulin (g/dL)

4.4

-

AG Ratio

0.9

-

Colour

Pale yellow

-

Appearance

Clear

-

Leucocytes (/hpf)

10-12

-

RBCs (/hpf)

Absent

-

Epithelial cells

5-6

-

Casts

Absent

-

Crystals

Absent

-

Bacteria

Present

-

Hematocrit (PCV)

31.4

-

MCV

74.2

-

MCH

22.5

-

MCHC

30.3

-

RDW

14.8

-

PDW

11.70

-

MPV

10.00

-

P-LCR

25.40

-

Reaction

<=5.0

-

Specific gravity

<=1.005

-

Protein

Negative

-

Sugar

Negative

-

Ketone bodies

Negative

-

Urobilinogen

Normal

-

Bile pigment

Negative

-

NIT

Negative

-

RNP/Sm

-

Negative

Sm

-

Negative

SS-A

-

Negative

Ro-52

-

Negative

SS-B

-

Negative

Scl-70

-

Negative

PM - Scl

-

Negative

Jo-1

-

Negative

CENP B

-

Negative

PCNA

-

Negative

ds DNA

-

Negative

Nucleosome

-

Negative

Histones

-

Negative

Rib P-Protein

-

Negative

AMAM2

-

Negative

 

Please proceed for discussing the case..