Pitfalls in Diagnosing Seropositive Rheumatoid Arthritis: Haematologic Malignancy Presenting as an Autoimmune Disease (original) (raw)

2018, JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH

A 24-year-old lady presented to the Rheumatology clinic of a tertiary care hospital with complaints of painful swelling of small joints of bilateral upper limbs, knees and ankles associated with early morning stiffness lasting more than half an hour for almost six months. This was associated with a feverish feeling which was intermittent, and without chills and rigors. However, there was no documented fever. Initial fever workup done by the treating physician on OPD basis was unremarkable. With time, the shoulders and elbows also were affected. Past medical, family, personal and social history were insignificant. Her blood counts, liver and renal function tests were within normal limits [Table/Fig-1]. However, she was found to be positive for ACPA in high titers (375 IU/mL, normal <5 IU/mL) though the Rheumatoid Factor (RF) was negative. She was diagnosed as Rheumatoid Arthritis (RA) and started on daily tablet hydroxychloroquine 200 mg twice daily and tablet diclofenac 50 mg on demand. She did not show any improvement even after three months. Later on she developed shortness of breath on exertion for which she was evaluated and revealed to have anaemia and thrombocytopenia for which she had been referred to our centre. General and systemic examination revealed severe pallor, pericardial rub, flow murmurs over the heart and hepatosplenomegaly. Musculoskeletal examination revealed synovitis of wrists, metacarpophalangeal, proximal interphalangeal, elbows and ankle joints. She was admitted as a case of connective tissue disorder probably Systemic Lupus Erythematosus (SLE) based on presence of polyarthritis, anaemia and pericardial rub and for further evaluation in this regard. Laboratory results revealed anaemia, leukocytosis, thrombocytopenia [Table/Fig-1]. Erythrocyte Sedimentation Rate (ESR) was 30 mm in first hour (normal range 0-20 mm in first hour for females by Westergrens method). Antinuclear Antibody (ANA) and RF were negative.