Talks
Presentation Type
Oral Presentation
Discipline Track
Translational Science
Abstract Type
Case Report
Abstract
Background: Rheumatoid arthritis affects 1.3 million adults in US and can be challenging to diagnose. Clinicians need to develop a good sense of pretest probability, or likelihood of this disease, before initiating testing. This case explores the association between palmar erythema, rheumatoid arthritis, the differential diagnoses and testing available.
Case presentation: This case involves a 55 year old woman with no past medical history who is presenting to the clinic with a 1 year duration of 7 out of 10 throbbing pain of the bilateral palms. There is no arthralgia. The pain worsens with activities that involve the hands and she denies stiffness. It is associated with episodic numbness in the median nerve distribution bilaterally which sometimes wakes her up at night. She denies fever or weight loss. The patient denies chronic illness, history of family illness, tobacco, alcohol, drug or current medication use. She has been treated in the past year for migraine headaches with sumatriptan and for unilateral carpal tunnel with gabapentin. On examination bilateral palms are diffusely erythematous and edematous with some pannus appreciated in the PIP joints. Tinel sign was positive bilaterally. We explored a broad differential including osteoarthritis, inflammatory arthritis, infectious. Our labs included Anti-CCP and RF which both came back negative.
Conclusions: Classically, the finding of palmar erythema should prompt investigations into hepatic, endocrine, autoimmune, infections, or neoplastic processes. The additional finding of carpal tunnel warrants investigations into musculoskeletal processes. Features of carpal tunnel include numbness, tingling, burning, pain primarily in the thumb and index, middle, and ring fingers. Features of osteoarthritis include pain during movement, stiffness, tenderness, loss of flexibility, bone spurs and swelling. Features of rheumatoid arthritis include pain, stiffness, tenderness, weight loss, fever, fatigue, weakness. Between 1 and 5 percent of patients with rheumatoid arthritis present with carpal tunnel syndrome. Accordingly, seeing the combination of palmar erythema and bilateral carpal tunnel should prompt investigations into rheumatoid arthritis as the culprit. Rheumatoid factor has a 60-90% sensitivity and 85% specificity for rheumatoid arthritis. Anti-CCP antibodies have a sensitivity of 62-75% and specificity of 94-99%. Physical examination can be used to suggest the diagnosis of rheumatoid arthritis. These include reduced grip strength, palmar erythema, and thickening of the flexor tendons. A survey of the literature reveals that rheumatoid vascular changes can lead to palmar erythema. Due to the combination of palmar erythema, bilateral carpal tunnel syndrome, and the relatively low sensitivities of rheumatoid factor and anti-CCP antibodies in rheumatoid arthritis, clinicians should maintain a high degree of suspicion for rheumatoid arthritis with this clinical presentation, even in the absence of positive serum markers.
Academic/Professional Position
Medical Student
Academic/Professional Position (Other)
MS4
Recommended Citation
Jain, Prakhar and Chang, Chelsea, "Signs of Rheumatoid Arthritis with Negative Serum Markers: A Diagnostic Challenge" (2024). Research Symposium. 16.
https://scholarworks.utrgv.edu/somrs/2023/talks/16
Included in
Signs of Rheumatoid Arthritis with Negative Serum Markers: A Diagnostic Challenge
Background: Rheumatoid arthritis affects 1.3 million adults in US and can be challenging to diagnose. Clinicians need to develop a good sense of pretest probability, or likelihood of this disease, before initiating testing. This case explores the association between palmar erythema, rheumatoid arthritis, the differential diagnoses and testing available.
Case presentation: This case involves a 55 year old woman with no past medical history who is presenting to the clinic with a 1 year duration of 7 out of 10 throbbing pain of the bilateral palms. There is no arthralgia. The pain worsens with activities that involve the hands and she denies stiffness. It is associated with episodic numbness in the median nerve distribution bilaterally which sometimes wakes her up at night. She denies fever or weight loss. The patient denies chronic illness, history of family illness, tobacco, alcohol, drug or current medication use. She has been treated in the past year for migraine headaches with sumatriptan and for unilateral carpal tunnel with gabapentin. On examination bilateral palms are diffusely erythematous and edematous with some pannus appreciated in the PIP joints. Tinel sign was positive bilaterally. We explored a broad differential including osteoarthritis, inflammatory arthritis, infectious. Our labs included Anti-CCP and RF which both came back negative.
Conclusions: Classically, the finding of palmar erythema should prompt investigations into hepatic, endocrine, autoimmune, infections, or neoplastic processes. The additional finding of carpal tunnel warrants investigations into musculoskeletal processes. Features of carpal tunnel include numbness, tingling, burning, pain primarily in the thumb and index, middle, and ring fingers. Features of osteoarthritis include pain during movement, stiffness, tenderness, loss of flexibility, bone spurs and swelling. Features of rheumatoid arthritis include pain, stiffness, tenderness, weight loss, fever, fatigue, weakness. Between 1 and 5 percent of patients with rheumatoid arthritis present with carpal tunnel syndrome. Accordingly, seeing the combination of palmar erythema and bilateral carpal tunnel should prompt investigations into rheumatoid arthritis as the culprit. Rheumatoid factor has a 60-90% sensitivity and 85% specificity for rheumatoid arthritis. Anti-CCP antibodies have a sensitivity of 62-75% and specificity of 94-99%. Physical examination can be used to suggest the diagnosis of rheumatoid arthritis. These include reduced grip strength, palmar erythema, and thickening of the flexor tendons. A survey of the literature reveals that rheumatoid vascular changes can lead to palmar erythema. Due to the combination of palmar erythema, bilateral carpal tunnel syndrome, and the relatively low sensitivities of rheumatoid factor and anti-CCP antibodies in rheumatoid arthritis, clinicians should maintain a high degree of suspicion for rheumatoid arthritis with this clinical presentation, even in the absence of positive serum markers.