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Clinical photographs
Microscopic slide of rheumatoid nodule, heart and kidney
CASE STUDY 15 – a middle aged man with rheumatism and widespread symptoms
A forty nine year old ex-bus driver had had to take early retirement because of progressive rheumatoid arthritis with fairly widespread joint involvement. He has poor upper limb function but his mobility has been reasonably well maintained until recently. He gradually loses weight, feels exhausted but denies a particular flare in his joints. He is anaemic on examination and has multiple subcutaneous nodules on his elbows, fingers, and feet. Some months later he develops several punched-out ulcers on the skin overlying his ankles and dorsum of the foot. They progress rapidly. Biopsy of the edge of an ulcer confirms necrotising vasculitis and he is treated with pulse cyclophosphamide and steroids.
Investigations |
Full blood count - Hb 7.6 g/dl, MCV 75fl, MCH 24 pf, MCHC 28%, ESR 120, WCC 12000 cells/mm3, Platelets 587,000 mm3 Urea/electrolytes - Sodium 136 mmol/l, Potassium 3.2 mmol/l, Urea 5.1 mmol/l Immunology - IgM Rheumatoid Factor titre 2400 Antinuclear antibody +ve |
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Clinical photographs Microscopic slide of rheumatoid nodule, heart and kidney |
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CASE STUDY 16 – A young woman with joint pain and a rash
A twenty-five year old housewife notices stiffness in the hands and feet in the morning and tiredness. She has a past history of thrombocytopenic purpura. Her symptoms increase in severity but her family doctor can find no signs of effusion in her joints. A few weeks later she develops a rash on the face, which seems to be aggravated by sunlight. The family doctor performs an ESR, which is elevated and refers her to the hospital. She is diagnosed and responds to treatment with hydroxychloroquine. Some months later she is troubled with recurrent chest symptoms, which do not respond to courses of antibiotics. After hospital review she settles following a short course of oral prednisolone.
Investigations |
Full blood count - Hb 10.2 g/dl, MCH 28 pg, MCHC 31%, WCC 1500 cells/mm3 ESR 76 mm/hr, Platelet 110,000/mm3 Urea/electrolytes-
Sodium 139 mmol/l, Potassium 4.4 mmol/l, Urea 8 mmol/l Anti-nuclear antibody litre 160 IgM Rheumatoid factor titre 20 Anti-Ro antibody + ve Ds DNA antibody 14 - |
Resources Provided |
Clinical photograph Microscopic slide of skin |
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Topic Objectives |
· List the differential diagnosis of this condition · List the common auto-immune rheumatic disorders · Describe useful features which help to differentiate it from rheumatoid arthritis · Describe the pathological features of organ involvement · Construct an investigation algorithm with particular emphasis on antibody tests · Discuss the key principles of management with specific reference to the management of this patient · Discuss the mechanisms of action, side effects, contra-indications and monitoring of anti-rheumatic drugs used in this case · What are the features of prognostic significance? |
CASE STUDY 17 – An elderly gentleman with muscular pain and weakness
A seventy-five year old gentleman with a history of ischaemic heart disease presents with a 12-week history of increasing muscle pain, immobility and stiffness. Previously very active, only limited by angina, he is now unable to get out of bed in the morning without help. Increasingly he has to use both handrails to pull himself upstairs, and has difficulty holding his arms up to shave. In consultation with his family doctor he admits that he can barely look after himself, although he is the primary carer for this disabled wife. His appetite is poor. He has noted an increase in headaches but denies any other symptoms, specifically visually disturbance. The headaches he thinks might be related to taking his wife’s “arthritis tablets”.
On examination there was evidence of weight loss of 7kg, and he looked depressed. Joint examination was normal. However, the power in the proximal muscles of his arms and legs is 3+/5. He needed help out of a chair. Distal power was normal. There was minimal temporal tenderness.
Investigations |
Full blood count - Hb 11 g/d/, MCV 82 fl, MCHC 34%, WCC 10,700 cells/mm3, ESR 120 /hr, CRP 86 mg/dl, Platelet 384,000/mm3 Urea/electrolytes - Sodium 140 mmol/l, Potassium 4.5 mmol/l, Urea 12.2 mmol/l, Alkaline phosphatase 160 u/l, Calcium 2.4 mmol/l Thyroid function - Normal |
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Microscopic slide temporal artery biopsies |
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CASE STUDY 18 – A middle-aged lady with painful discoloured fingers
A middle-aged apple processor notices persistent itching in the skin of her forearms soon followed by progressive but episodic cold inducted pain, coldness and colour changes in the fingers of the hands. Exposure to cold causes first white and numb fingertips, which then becomes blue, and finally red on subsequent recovery and warming. The skin itch subsides but over the next few months she notices slight thickening and shininess of the skin on her hands. The cold induced symptoms become worse and being to involve her toes and the tip of her nose in addition to the hands. She has difficulty in swallowing solid foods, such as bread and meat and has troublesome heartburn. The small joints of her hands and wrists are stiff and sore in the mornings and he is unable to grip apples at work. She feels a little breathless on moderate exertion despite losing a little weight. She is a lifelong non-smoker.
Investigations |
Full blood count - Hb 9.8 g/dl, MCH 27 pg, MCHC 31%, ESR 17 mm/hr Urea/electrolytes - Sodium 135 mmol/l, Potassium 4.6
mmol/l, Urea 9 mmol/l, |
Resources Provided |
Clinical photography Microscopic slides of skin and lung |
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CASE STUDY 19 – A young woman with widespread aches and pains
A twenty five year old housewife with two young children gives a two year history of widespread aches and pains. They are worse around the neck and shoulders, elbows, back, hips and knees. She is tired all the time and wakes from sleep without feeling refreshed. She notices a tingling feeling in her hands and finds that cold weather makes her worse. She has been tried on six or seven different NSAIDs and simple analagesics with no relief of symptoms. She feels stiff and sore all the time and says she is unable to carry on any longer, as attempts to keep up with housework aggravate her pains. She smokes 20 cigarettes daily and denies excess alcohol intake.
On examination she looks tired and drawn. General examination reveals no specific abnormalities. In the locomotor system there is no evidence of joint swelling but she is “jumpy” on touching the joints and there are particularly painful points in the muscles around the neck, supraspinatus belly, between shoulder blades and over the lateral aspects of the hips and medial aspects of the knees and elbows.
Investigations |
Hb 12.0 , ESR 5 mm/hr C-reactive Protein <6 Mg/L, Sodium 140 mmol/l, Potassium 4.3 mmol/l, Urea 4 mmol/l, Creatinine 60, autoantibody profile negative, Chest XR normal |
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