A 25-year-old female with polyarthralgia, fever, dry mouth and eyes

Case quiz study - 23/11/2022

A case quiz study exposes you to a step-by-step analysis of the case discussed.
The MCQs poser is placed in critical junctures where the reader can exercise his thoughts in diagnosis by answering them.
It’s designed to help the reader to learn about the clinical features, investigations to be performed, any clinical interventions, and how to conclude the diagnosis
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Note Correct answers and a Discussion of the case from an expert are available after completing all the Questions.

Patient history

Patient history - 2

Patient history - 3

previous clinical and laboratory investigations

1 / 4

The probable diagnosis to be considered in the present case except

Viral arthritis

Rheumatoid arthritis

Osteoarthritis

Reactive arthritis

X-Ray of hands

2 / 4

X-Ray of hands indicates

No abnormalities

Rheumatoid arthritis

Fracture in wrist

osteoporosis

current clinical and laboratory investigations

3 / 4

What are the further tests to be considered?

Inflammatory parameters, ANA

Rheumatoid factor, Anti-CCP, and ANA

ANA, Rheumatoid factor

Anti-CCP and Rheumatoid factor

further tests

4 / 4

The case is finally be diagnosed as

Reactive arthritis

Rheumatoid arthritis

Post-viral arthritis

Connective tissue disease

Discussion of the case

The 25-year-old female was having acute onset polyarthralgia, accompanied by fever, and dry mouth and eyes for 10 days. Both small and large joints were involved. In addition, she had low backache with minimal stiffness. The patient had clinical features of inflammatory arthritis, while her CRP and ESR were within normal limits at both visits. The patient had a maternal family history of RA.

The probable diagnoses are viral or post-viral arthritis, reactive arthritis, and inflammatory arthritis like RA, CTD, etc. The X-ray of the hands was normal, and the changes may not be generally visible in short-term arthritis. The major challenge in such kind of presentations is whether the patient requires further evaluation, especially when considering the chances of having viral infections including chikungunya. Based on the patient history, the physician should be able to strike a balance between over-investigation and the chances of missing an early diagnosis.

As per the European League Against Rheumatism (EULAR) guidelines, the following parameters need to be evaluated in a patient with arthralgia without clinical arthritis and other diagnoses or other explanations for the arthralgia.¹

History collection

▸ Joint symptoms of recent onset (duration <1 year)

▸ Symptoms of MCP joints

▸ Duration of morning stiffness ≥60 min

▸ Most severe symptoms present in the early morning

▸ Presence of a first-degree relative with RA

Physical examination

▸ Difficulty with making a fist

▸ Positive squeeze test of MCP joints.

The possibility of rheumatoid arthritis should be considered in patients with the afore mentioned symptoms. Since the present case had a positive family history of RA, it is advisable to investigate RF and anti-CCP. A closer follow-up till the improvement of joint symptoms is preferable. Considering the presence of dry eyes and mouth, ANA should be evaluated to exclude the remote possibility of Sjogren's syndrome and sarcoid. The RF, anti-CCP, and ANA were negative in the present patient. Follow-up after 6 weeks indicated normal inflammatory parameters and reduced joint pain.

Final Diagnosis

Post-viral arthritis

Learning points

If there is a clinical possibility of rheumatoid arthritis, further evaluation should focus on its exclusion and the patient should be followed till the condition is resolved.

Reference

van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJJ, Brouwer E, Codreanu C, Combe B, et al. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis. 2017 Mar;76(3):491–6.

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