Patient and observation
Patient Information: We report the case of a 38-year-old female
with no significant medical history.
Clinical Findings : She presented with chief complaints of 4
months of progressively worsening pain of her small hand joints, wrists,
knees, and ankles symmetrically. She also complained of morning
stiffness lasting two hours and was exhausted throughout the day.
Symptoms begun one month after a COVID-19 infection confirmed by a
positive throat swab. The infection was mild; the patient only
experienced symptoms of cough, fever, chills, without arthralgia and did
not need hospitalization nor oxygen therapy.
She did not report any fevers, chills, night sweats, weight loss or rash
upon presentation. She had no history of joint problems, gonorrhea,
chlamydia, diarrhea, or uveitis. She denied alcohol use or smoking
cigarettes. Her maternal aunt has Rheumatoid Arthritis.
Diagnostic assessment: Initial laboratory workup included a
complete blood count which was within normal limits, ESR of 13 mm, and
CRP of 4,3 mg/L. Immunological workup revealed elevated antinuclear
antibodies titer (1:640), negative ENA and dsDNA antibodies, positive
rheumatoid factor measured by ELISA (62,29) and positive anti-cyclic
citrullinated peptide (anti-CCP) antibodies (237,39). Serology tests for
hepatitis B virus and hepatitis C virus were negative. Joint x-rays
including wrists, hands, knees, ankles, feet showed no evidence of
erosions. Hands Ultrasound did not reveal any signs of synovitis.
Hands MRI showed synovitis of both distal radio-ulnar joints and
metacarpophalangeal joint of the left second compartment. It also showed
inflammation around extensor carpi ulnaris tendons with synovial
enhancement of the tendon sheaths suggestive of tendonitis. No adjacent
osseous destruction was found.
Diagnosis: Although our patient presented with inflamed joints
one month after a viral infection (COVID-19), it is less likely to be a
reactive arthritis since she presented with chronic and symmetric
polyarthritis of small and large joints without increased inflammatory
markers (ESR and CRP) and had positive anti-CCP antibodies.
Our patient meets the formal criteria for the diagnosis of Rheumatoid
Arthritis according to the current ACR/EULAR 2010 criteria: joint
involvement of more than 10 joints for a period of more than 6 weeks
with high positive ACPA. No striking extra-articular signs or symptoms
were found to suggest a different systemic immune disease such as
systemic lupus erythematosus (SLE). Disease activity was moderate with a
DAS28-ESR of 4.6.
Therapeutic interventions: Treatment was initiated with
methotrexate and non-steroidal anti-inflammatory drugs.
Follow-up and outcome of interventions: After treatment, an
improvement of the symptoms as noted with a DAS28 ESR after 2 and 5
months at 3.7 and 3.1, respectively
Informed Consent: The patient gave her consent for publishing
her case with absolute respect of anonymity.