Case Presentation: A 47-year-old female with a history of HR+/HER2- breast cancer status post chemotherapy and radiation, currently on exemestane, and bilateral carpal tunnel syndrome, presented with pain and swelling in her left hand, fingers, wrist, and both knees for five days. She reported difficulty walking due to the pain. She denied any trauma, intravenous drug use, or recent sexual activity. Review of systems was notable for fatigue. On examination, there was tenderness in the left hand, wrist, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints, with inability to make a fist. Swelling was also noted in the left ankle and right foot. Laboratory studies revealed a normal CBC, CMP, and CK. ESR was 22, and CRP was 13.3. Rheumatoid factor was elevated at 197, anti-CCP was >300, and ANA was positive at 1:640 with a homogeneous pattern. X-rays of the left hand and bilateral knees were normal. The patient was started on NSAIDs. Rheumatology was consulted and initiated a prednisone taper, which resulted in significant improvement in her pain.
Discussion: This case is unique because it highlights the initial presentation and diagnostic approach to rheumatoid arthritis (RA) in the hospital setting. RA is most often diagnosed in the outpatient setting, where patients typically present with joint pain, swelling, and morning stiffness. This patient’s symptoms were debilitating and required hospital admission. The diagnosis of RA is primarily clinical, supported by laboratory findings and imaging. In early RA, only 30-40% of seropositive patients show bone changes on X-ray, and up to 70% develop bony erosions after more than 12 months of symptoms. Initial management includes NSAIDs and corticosteroids to control acute symptoms, followed by the initiation of disease-modifying antirheumatic drugs (DMARDs), with methotrexate as the first-line agent. Seropositivity indicates a poorer prognosis and may necessitate earlier use of biologic DMARDs, such as TNF inhibitors. The treat-to-target strategy emphasizes aggressive therapy at the time of diagnosis to minimize disease activity and prevent the development of joint deformities.
Conclusions: RA is infrequently diagnosed in the hospital setting, so hospitalists need to maintain a high index of suspicion when patients present with polyarticular symmetrical arthritis. Prompt diagnosis is essential to initiate early treatment and prevent long-term joint destruction.