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.