A 61-year-old woman who recently immigrated to the United States has a long history of "joint problems." She began to have pain in her hands at age 30, and her symptoms have been intermittent but progressive since then. The symptoms were treated with nonsteroidal anti-inflammatory drugs when the pain was most severe. The patient also has a history of hypertension and chronic anemia. She does not smoke cigarettes or use illicit drugs. Family history is insignificant. On examination, there is gross deformity of multiple joints in both hands. X-ray findings are shown in the image below.
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The disease process responsible for the radiographic findings would most likely affect which of the following?
Clinical features of rheumatoid arthritis | |
Clinical presentation |
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Laboratory/ |
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anti–CCP = anti–cyclic citrullinated peptide; DIP = distal interphalangeal; ESR = erythrocyte sedimentation rate; MCP = metacarpophalangeal; MTP = metatarsophalangeal; PIP = proximal interphalangeal. | |
This patient has chronic polyarticular arthritis, primarily involving the small joints of the hands. Her arthritis is progressive, leading to joint destruction and ulnar deviation of the digits, consistent with rheumatoid arthritis (RA). The symptoms of RA may be relieved temporarily with nonsteroidal anti-inflammatory drugs or systemic glucocorticoids, but long-term use of disease-modifying antirheumatic drugs is recommended to avoid progressive joint destruction.
In addition to the metacarpophalangeal and proximal interphalangeal joints in the hands (and metatarsophalangeal joints in the feet), RA may also involve the wrists, elbows, knees, and ankles. Cervical spine involvement is also common in longstanding disease, and may lead to severe pain and disability due to spinal instability with potential radiculopathy/cord compression. The hips and lumbosacral joints are usually spared in RA.
(Choice B) The lumbar spine is only rarely involved in RA but is commonly affected by osteoarthritis.
(Choice C) Arthritis of the sacroiliac joints is characteristic of the seronegative spondyloarthropathies (ankylosing spondylitis, reactive arthritis, arthritis associated with inflammatory bowel disease, psoriatic arthritis). These conditions are seen most commonly in patients who carry the human leukocyte antigen B27 allele.
(Choice D) Arthritis involving the thoracic spine is uncommon and is usually due to osteoarthritis or spondyloarthritis.
Educational objective:
Rheumatoid arthritis causes progressive joint destruction involving the hands, wrists, elbows, and knees. Cervical spine involvement can lead to spinal instability and cord compression.