Rheumatology Cases for the

Internist
Marc C. Hochberg, MD, MPH
Professor of Medicine
Head, Division of Rheumatology and Clinical Immunology
Vice Chair, Department of Medicine
University of Maryland School of Medicine
Director, Medical Care Clinical Center
VA Maryland Health Care System
 Objectives
• To present and discuss three cases that
represent the most common reasons for
referral to my academic rheumatology
practice at both the University of Maryland
and Baltimore VA Medical Center.
 Case 1: History
• 45-year-old woman who presents for evaluation
of polyarticular joint pain of several years
duration.
• She admits to AM stiffness lasting ~1 hour, gel
phenomenon, but denies joint swelling or
redness.
• Review of systems is positive for difficulty falling
asleep, difficulty staying asleep, snoring, fatigue
and diffuse myalgias; pertinent negatives include
lack of fever or weight loss.
 Case 1: History
• There is no h/o sicca symptoms, rash, mucosal
ulcers, Raynaud phenomenon or Lyme disease.
• Family history is non-contributory.
• Social history is positive for modest alcohol
consumption (average 4 drinks per week), former
smoker, no illegal drug use. She lives in Baltimore
City and currently works as an administrative
assistant.
 Case 1: Physical Examination
• Normal vital signs
• No evidence of active or chronic synovitis,
joint effusions or deformity.
• Normal muscle strength.
• Tender at 14/18 “tender points.”
• Remainder of examination, including
neurologic exam, is within normal limits.
 Fibromyalgia: Treatment
• Non-pharmacologic modalities
– Patient education, good sleep hygiene, cognitive
behavioural therapy and aerobic exercise program;
consider acupuncture, tai chi and/or yoga
• Pharmacologic modalities
– Amitriptyline or cyclobenzaprine followed by
duloxetine or milnaciprin, pregabalin or a
combination of the above
– Avoid opioid analgesics!
 2017 EULAR Management Recommendations.
©2017 by BMJ Publishing Group Ltd and European League Against Rheumatism G J Macfarlane et al. Ann Rheum Dis 2017;76:318-328
Case 1: Questions
 Case 2: History
• 45-year-old woman who presents for evaluation
of polyarticular joint pain of several months
duration.
• She admits to AM stiffness lasting ~1 hour, gel
phenomenon and joint swelling with difficulty
performing her usual daily activities.
• Review of systems is positive for fatigue,
depressed mood, low grade fever, anorexia and
weight loss.
 Case 2: History
• Positive for h/o sicca symptoms; however, she
denies rash, mucosal ulcers, chest pain, muscle
weakness or Raynaud phenomenon.
• Family history is positive for RA in her mother.
• Social history is positive for modest alcohol
consumption (average 4 drinks per week), current
smoking, but no illegal drug use. She lives in
Baltimore County and currently works as an
administrative assistant.
 Case 2: Physical Examination
• Normal vital signs
• Combination of both active and chronic synovitis
involving all PIP and MCP joints of both hands and both
wrists as well as tenderness across MTP joints of the
feet bilaterally.
• Normal proximal muscle strength; however, grip
strength is reduced bilaterally.
• No subcutaneous nodules or skin rash
• Remainder of examination, including neurologic exam,
is within normal limits.
16
18
 Case 2: Laboratory Evaluation
• CBC with differential
• Chemistry profile
• Acute phase reactants
• Serology
– Rheumatoid factor
– Anti-citrullinated peptide antibodies (ACPA)
 Case 2: Imaging Evaluation
• Definite
– Plain radiographs of affected joints
• Possible
– Color Doppler ultrasound
– Magnetic resonance imaging
22
 RA: Approach to Management
• Refer to rheumatologist!
• All patients with active RA should receive a
disease-modifying antirheumatic drug (DMARD)
• All patients should receive non-pharmacologic
modalities including patient education, OT/PT
• NSAIDs and glucocorticoids are adjunctive
agents for control of symptoms
Case 2: Questions
 Case 3: History
• 45-year-old man who presents for evaluation of
polyarticular joint pain and swelling involving the left
foot/ankle, right knee and wrist of several weeks
duration.
• He has a h/o recurrent episodic monoarthritis
previously involving the big toe bilaterally, left ankle
and right elbow. These were previously treated with
OTC NSAIDs; he has never had a joint aspirate or been
treated with colchicine or urate lowering therapy.
• Review of systems is positive for low grade fever and
anorexia.
 Case 3: History
• Positive for h/o hypertension treated with HCTZ
and lisinopril, and hyperlipidemia treated with
simvastatin.
• Family history is positive for kidney stone and
gout in his father.
• Social history is positive for moderate alcohol
consumption (average 10 drinks per week),
current smoking, but no illegal drug use. He lives
in Baltimore County and formerly worked at
Bethlehem Steel.
 Case 3: Physical Examination
• Normal vital signs
• Combination of active synovitis involving left foot
and ankle, right knee and right wrist with
warmth, tenderness and soft-tissue swelling;
right knee effusion present with positive bulge
sign.
• Subcutaneous nodule in right olecranon bursa.
• Remainder of examination is within normal limits.
 Correct Nomenclature
• Gout is a chronic inflammatory arthritis that results
from monosodium urate (MSU) crystal deposition in
tissues or joints resulting from supersaturation of uric
acid in extracellular fluids
• Gout is a disorder of uric acid metabolism
• Hyperuricemia is defined as serum uric acid >2 SD
above the mean (> 7.0 mg/dL for men, > 6.0 mg/dL for
women)
• Hyperuricemia is a necessary but not sufficient
precursor to gout
 Gout: Stages
• Asymptomatic hyperuricemia
• Acute episodic monoarthritis
• Intercritical gout
• Chronic polyarthritis, often with tophaceous
deposits
 Case 3: Evaluation
• Laboratory tests
– CBC with differential
– Chemistry profile, including serum uric acid
– Acute phase reactants
• Imaging
– Plain radiography
– Ultrasonagrapy (double contour sign)
– Dual-energy CT
 Gout: Treatment of Arthritis
• Treat acute/chronic arthritis
– Colchicine
– NSAIDs
– Glucocorticoids
– IL-1 inhibition
Gout: Prevention of Recurrent Attacks
• Oral colchicine
• Urate lowering therapy
– Xanthine oxidase inhibition
• Allopurinol
• Febuxostat
– Uricosuric agents
• Probenecid
• Lesinurad (ZurampicTM) specific URAT1 inhibitor
Case 3: Questions
 Choosing Wisely: Rheumatology
• Don’t test ANA sub-serologies unless the ANA is
positive in a clinically significant titer
• Don’t test for Lyme disease without an exposure
history and appropriate exam findings
• Don’t perform MRI of the peripheral joints to
monitor inflammatory arthritis
• Don’t prescribe biologic DMARDs for RA before a
trial of MTX or other conventional DMARD

American College of Rheumatology. Released February 21, 2013.

Approved by ACR Board of Director, August 2015 (modified by MCH)