Images

Interpret these images.

Case description

• 64 year old male
• Longstanding smoking history
• Recent diagnosis of squamous cell carcinoma of the neck
• Now endorsing pain and swelling of the small joints of the hands and feet
• He has also noted a skin rash on his fingers
• On examination, small joint polyarthritis with 8 swollen joints involving scattered PIP’s, MCP’s, DIP’s
• Small erythematous papules on the distal aspect of the phalanges

29 F with history SLE presenting with psychosis.

What is this study, what are the findings and what is your diagnosis?

Clinical Presentation

History

• 38M, recently moved to your area, seeking rheumatological assessment for chronic MCP, PIP, DIP, MTP pain and swelling
• He had seen a rheumatologist previously, but he tells you “I wasn’t very reliable in going to appointments”
• Treated with prednisone courses on and off
• Was prescribed methotrexate previously but the prescription was not renewed after 3 months when he neglected to have screening labs done
• Currently: morning stiffness of 1.5 hours duration
• Intermittent swelling and pain of scattered MCP’s, PIP’s, MTP’s

Physical Examination

• Appears well.
• Height: 178cm. Weight: 110kg.
• Chronic joint deformities including:
• Left hand - swelling of 2nd MCP, PIP, 4th MCP, PIP
• Right hand - right wrist swelling
• Physical examination otherwise unremarkable, without rashes, nail changes, pulmonary, cardiac manifestations
• No skin nodules

Labs

• Complete Blood Count, Creatinine, liver enzymes normal
• Rheumatoid Factor negative, Cyclic Citrullinated Peptide negative
• ESR 22, CRP 14

Clinical Presentation

History

• 23 year old woman
• History of inflammatory arthritis predominantly affecting MCP’s, PIP’s, wrists, MTP’s for 8 years
• Previously followed in a pediatric clinic but was lost to follow-up
• Currently taking methotrexate at 20mg qweekly, Naproxen prn
• Majority of joints no longer bothersome, however left wrist persistently painful, which has been longstanding
• 45 minutes of morning stiffness
• Review of systems and social history are non-contributory

Physical Examination

• Appears well.
• Temp 36.0, HR 80, bp 104/62
• Borderline swelling of bilateral wrists
• Decreased range of motion of left wrist to 15 degrees of extension, 30 degrees of flexion

Labs

• Complete Blood Count - wbc 4.6, Hgb 120, PLTs 315
• Creatinine 62
• Alanine Aminotransferase 18, Alkaline Phosphatase 114, Albumin 38
• Rheumatoid Factor 86, Cyclic Citrullinated Peptide >250
• Antinuclear Antibody negative
• Hepatitis serology negative
• ESR 18, CRP 4

18M presenting with multifocal soft tissue lobulated hard masses. There is family history of soft tissue masses.

What is the study, findings and diagnosis?

Clinical Presentation

History

• 52 year old man
• History of hypertension and chronic kidney disease with stable baseline creatinine of 120
• 1 month history of pain and swelling in the left wrist following a twisting injury when lifting a heavy object
• Morning stiffness of 2 hours
• No other joints affected
• Review of systems and social history non-contributory

Physical Examination

• Appears well
• Temp 36.5, HR 72, bp 142/80
• Swelling of the left wrist with mild erythema, tenderness
• Range of motion limited to 45 degrees of flexion and 20 degrees of extension
• No other swollen or tender joints
• Remainder of the examination unremarkable

Synovial Fluid Analysis

• Aspirate was attempted in the clinic, however no synovial fluid was obtained
• Imaging was ordered to assist in diagnosis and for synovial fluid aspiration if fluid seen

Images

Review the following images. What are the pertinent findings, and diagnosis?

Case description

• 61 year old female, retired teacher
• Has had a 4 week history of painful, swollen hands
• Has had difficulty with activities of daily living
• 4 hours of morning stiffness
• Has felt some fatigue, though otherwise no other symptoms
• Otherwise healthy

Clinical Presentation

History

• 65 year old woman, retired, avid skier
• Diagnosed with rheumatoid arthritis four years ago
• Treated with methotrexate, leflunomide, golimumab for 2 years
• Recently switched from golimumab to tocilizumab for lack of efficacy due to pain and swelling in the ankles and pain in the MTP’s
• Presents today with gradually increasing pain and swelling in the ankles and feet that has progressed to the point where she is having difficulty walking
• No trauma
• Feeling systemically well
• No fevers, no weight loss

Physical Examination

• Appears uncomfortable
• Antalgic gait when walking into the examination room
• Bilateral ankle swelling
• Tenderness of all MTP’s, midfoot in general to palpation
• No swollen joints in the upper extremity

Labs and Synovial Fluid Analysis

Labs

• Complete Blood Count, Creatinine, liver enzymes normal
• Rheumatoid Factor negative, Cyclic Citrullinated Peptide >250
• ESR 22, CRP 14

Synovial fluid analysis

• Aspirate was attempted in the clinic, however no synovial fluid was obtained
• Imaging was ordered to assist in diagnosis and for synovial fluid aspiration

Ultrasound

• Ultrasound revealed bilateral ankle synovitis
• No appreciable fluid available for aspirate

Further History

• Started 40mg of prednisone for presumed rheumatoid arthritis flare
• Seen in follow-up 2 weeks later
• • Very minimal improvement in pain and swelling
  • Unable to ambulate
  • Admitted to hospital for further work-up and pain control

What is the dominant finding in radiograph 1? What does radiograph 2 demonstrate?

Images

Review these MRI images. What is the most likely diagnosis?

Case description

• 61 year old female, retired teacher
• Has had a 4 week history of painful, swollen hands
• Has had difficulty with activities of daily living
• 4 hours of morning stiffness
• Has felt some fatigue, though otherwise no other symptoms
• Otherwise healthy

46F with SLE with mild bilateral knee pain.

What is the study, findings and diagnosis?