Read this case study and answer the questions:
A 60 year old Hispanic female with a recent diagnosis ofRheumatoid Arthritis, brought to this tertiarycare referral center by her daughters who reported a 2 monthhistory of worsening cognitive difficulty and decreased arousalsince the patient fell from a chair.
Two and a half years ago the patient began to loseweight. She initially experienced a rapid loss of weightfrom 160 to 130 pounds, but has continued to lose weight to thepoint where she now weighs 116 pounds. About nine months ago, herdaughters noticed a raised bilateral rashon herfeet and lower extremities with residualhyperpigmentation of her feet and the distalportion of her legs. Six months prior to her current presentation,she developed joint pains and subcutaneousnodules.
Diagnostic evaluation at that time revealed a Rheumatoid Factortiter of 1:1260 and an ANA of 1:160, with an elevated ESR. She wasdiagnosed with Rheumatoid Arthritis and has since been treated withregimens of non-steroidal medications and immunosuppresive therapy.At the time of evaluation her current regimen was Plaquenil andPrednisone.
Four months earlier she was noted by her Rheumatologist toexperience gait difficulties with "falling episodes". During thistime, she is also noted to have occasional fever and chills. Adiagnosis of Diabetes Mellitus was presumed secondary to steroidtherapy. Two months prior to presentation, she fell from a chairand has had rapid progressive decline in mental status since thattime.
Past Medical History: diet-controlled hyercholesterolemia;Family members deny prior diabetes, hypertension,seizure disorder,autoimmune disease or neurological disease.
Past Surgical History: hysterectomy in 1986 and a hernia repairin 1992.
Allergies: None
Medications: Prednisone 5 mg a day, Plaquenil 200 mg a day,Reglan, Ritalin, Paxil, and Premarin.
Social History: The patient lived alone in Corpus Christi, Texasuntil the onset of this illness. She had been divorced for 30 yearswith two adult daughters and two adult sons. She does not smoke orconsume alcoholic beverages.
Family History positive for Diabetes Mellitus-type II in one sonand a history of joint pains in one of the daughters; herex-husband is deceased secondary to gastric cancer
Physical Examination
B.P. B.P. 150/100 ; pulse 78 ; temperature 98.2 ; respirationswere regular at 20.
General: This is a thin Hispanic female lying in bed withoutsigns of respiratory compromise or signs of pain or discomfort. Sheis intermittently responsive to verbal stimuli.
HEENT: HEENT exam reveals anicteric sclera with no conjunctivalerythema. There are no oral mucosal lesions and the oropharynx isclear noting a palatine torus. The neck examination shows no JVD,no bruits, and no lymphadenopathy or thyromegaly.
Cardiovascular: Exam reveals a regular rhythm with normal rateand good S1 and S2. There is no significant murmur and no rub.
Chest: Exam reveals lung fields are clear to auscultation
Abdomen: Soft, non tender with bowel sounds present in all fourquadrants; there is no evidence of
hepatosplenomegaly; there is a PEG in place which is clean, dryand without evidence of induration, erythema, or exudate.
Skin: Examination reveals hyperpigmentation on the distalextremities and small subcutaneous nodules on the extensorsurfaces of the forearms.
Extremities: No signs of clubbing, cyanosis, or edema.
Neurological Examination
Mental Status
Attention: intermittently alert and responsive to verbalstimuli; she was not oriented to place or time; speech iswhispered, sparse, and slow; spontaneous speech is limited;comprehends simple commands but not complex commands, she couldperform simple repeats; a full MMSE score was not available but shewas reported to be unable to perform memory operations, write asentence, perform constructional tasks, and did not nameobjects.
QUESTIONS:
Which lab results do you think are most significant in helpingdiagnose this patient's rheumatoid arthritis?
What do you make of the nodules on this patient's forearms?
Which symptoms in this patient go along with the diagnosis ofrheumatoid arthritis?
Read this case study and answer the questions:
A 60 year old Hispanic female with a recent diagnosis ofRheumatoid Arthritis, brought to this tertiarycare referral center by her daughters who reported a 2 monthhistory of worsening cognitive difficulty and decreased arousalsince the patient fell from a chair.
Two and a half years ago the patient began to loseweight. She initially experienced a rapid loss of weightfrom 160 to 130 pounds, but has continued to lose weight to thepoint where she now weighs 116 pounds. About nine months ago, herdaughters noticed a raised bilateral rashon herfeet and lower extremities with residualhyperpigmentation of her feet and the distalportion of her legs. Six months prior to her current presentation,she developed joint pains and subcutaneousnodules.
Diagnostic evaluation at that time revealed a Rheumatoid Factortiter of 1:1260 and an ANA of 1:160, with an elevated ESR. She wasdiagnosed with Rheumatoid Arthritis and has since been treated withregimens of non-steroidal medications and immunosuppresive therapy.At the time of evaluation her current regimen was Plaquenil andPrednisone.
Four months earlier she was noted by her Rheumatologist toexperience gait difficulties with "falling episodes". During thistime, she is also noted to have occasional fever and chills. Adiagnosis of Diabetes Mellitus was presumed secondary to steroidtherapy. Two months prior to presentation, she fell from a chairand has had rapid progressive decline in mental status since thattime.
Past Medical History: diet-controlled hyercholesterolemia;Family members deny prior diabetes, hypertension,seizure disorder,autoimmune disease or neurological disease.
Past Surgical History: hysterectomy in 1986 and a hernia repairin 1992.
Allergies: None
Medications: Prednisone 5 mg a day, Plaquenil 200 mg a day,Reglan, Ritalin, Paxil, and Premarin.
Social History: The patient lived alone in Corpus Christi, Texasuntil the onset of this illness. She had been divorced for 30 yearswith two adult daughters and two adult sons. She does not smoke orconsume alcoholic beverages.
Family History positive for Diabetes Mellitus-type II in one sonand a history of joint pains in one of the daughters; herex-husband is deceased secondary to gastric cancer
Physical Examination
B.P. B.P. 150/100 ; pulse 78 ; temperature 98.2 ; respirationswere regular at 20.
General: This is a thin Hispanic female lying in bed withoutsigns of respiratory compromise or signs of pain or discomfort. Sheis intermittently responsive to verbal stimuli.
HEENT: HEENT exam reveals anicteric sclera with no conjunctivalerythema. There are no oral mucosal lesions and the oropharynx isclear noting a palatine torus. The neck examination shows no JVD,no bruits, and no lymphadenopathy or thyromegaly.
Cardiovascular: Exam reveals a regular rhythm with normal rateand good S1 and S2. There is no significant murmur and no rub.
Chest: Exam reveals lung fields are clear to auscultation
Abdomen: Soft, non tender with bowel sounds present in all fourquadrants; there is no evidence of
hepatosplenomegaly; there is a PEG in place which is clean, dryand without evidence of induration, erythema, or exudate.
Skin: Examination reveals hyperpigmentation on the distalextremities and small subcutaneous nodules on the extensorsurfaces of the forearms.
Extremities: No signs of clubbing, cyanosis, or edema.
Neurological Examination
Mental Status
Attention: intermittently alert and responsive to verbalstimuli; she was not oriented to place or time; speech iswhispered, sparse, and slow; spontaneous speech is limited;comprehends simple commands but not complex commands, she couldperform simple repeats; a full MMSE score was not available but shewas reported to be unable to perform memory operations, write asentence, perform constructional tasks, and did not nameobjects.
QUESTIONS:
Which lab results do you think are most significant in helpingdiagnose this patient's rheumatoid arthritis?
What do you make of the nodules on this patient's forearms?
Which symptoms in this patient go along with the diagnosis ofrheumatoid arthritis?
Related textbook solutions
Related questions
A 26-year-old woman presented with painful, stiff knees of 4 weeks duration. She had a 6-year history of Raynaud's phenomenon. On examination, she had bilateral effusions in both knee joints, but all other joints were normal. She had no skin lesions, muscle tenderness, proteinuria or fever. The results of relevant investigations are shown in Table C10.1. On the basis of these, a diagnosis of Systemic Lupus Erythematosus (SLE) was made and the patient treated with aspirin for her painful knees. She improved over 4 weeks and then remained symptom-free for 5 years. During this time, her antinuclear antibody remained positive at 1/80, her DNA-binding activity varied from 40 to 80%, and her C3 and C4 levels were occasionally low. Later, she developed a bilateral, butterfly rash across her cheeks, blotchy rash on her hands and thighs, consistent with active vasculitis and also presented with proteinuria, hematuria and glomerular nephritis. Her Raynaud's phenomenon concurrently became much worse. Following treatment with prednisolone, the skin manifestations gradually disappeared and the steroids were tailed off.
This patient presented with arthritis and Raynaud's phenomenon. She is unusual in that the arthritis of SLE usually involves small joints, but it is important to note that she remained perfectly well without treatment for 5 years, despite persistently abnormal serology.
Table C10.1 Investigations in Case 10.8.
| C-reactive protein | 8mg/l (normal) |
| Rheumatoid factor | Negative |
| Antinuclear antibody | Positive (titer 1/80; IgG class) |
| dsDNA-binding activity | 80% (NR 0-30% binding) |
| Antibodies to extractable nuclear antigens | Negative |
| Serum complement levels | |
| C3 | 0.35g/l (NR 0.65-1.30) |
| C4 | 0.05g/l (NR 0.20-0.50) |
| Serum immunoglobulins | |
| IgG | 22.0g/l (NR 7.2-19.0) |
| IgA | 3.8g/l (NR 2.0-5.0) |
| IgM | 1.2g/l (NR 0.5-2.0) |
| Biopsy of normal, sun-exposed skin (lupus band test) | Granular deposits of IgG and complement at dermo-epidermal junction |
1) Explain the immunological basis of her disease condition and the significance of her elevated levels of antinuclear antibodies (ANA).
2) Explain as to what caused her glomerular nephritis, vasculitis and bilateral skin rash.
3) How would you categorize the type of hypersensitivity reactions causing the above disease?
4) Explain how prednisolone helped to treat the symptoms.
5) Explain the biochemical mechanism of action of aspirin in its interaction with cyclooxygenase. Which class of macromolecules are affected by this interaction (inhibition) and state briefly a major side effect that may develop as a result of extensive aspirin therapy.
