Investigation and treatment
Laboratory investigations revealed a positive rheumatoid factor and the anti-ccp antibody was negative. The X-rays of the hands (Figure 2A and B) showed subluxation of the bilateral interphalangeal joint of the thumb, (Hitchhiker’s thumb deformity).
with these presentations, she was diagnosed with RA. She was initially started on Methotrexate 10 mg po/week and prednisolone 10 mg po/d. Throughout her course of treatment and follow up she has had multiple flare-ups because of poor drug adherence. After 9 years and 3 months of treatment and follow-up, she developed an erythematous non-itchy patch on both cheeks, alopecia, and oral ulcers on the buccal mucosa bilaterally. And physical examination this time revealed chronically swollen PIP and MCP joints in her hands.
On laboratory investigation Urinalysis showed Blood: +2, Protein: +3, RBC 5-8/ hpf, WBC: 3-5/hpf. 24 hours urine protein: 3024 mg/dl. ANA (qualitative): Positive, Anti-dsDNA Antibody: 1424.78 IU/ml (strongly positive), Anti Smith Antibody: 190 Units (Strongly positive).
Based on the above findings, a mixed connective tissue disease of systemic lupus erythematosus on top of rheumatoid arthritis, Rhupus, was considered and she was started on MMF (mycophenolate mofetil) 500 mg PO bid, chloroquine 250 mg PO/day, prednisolone 1mg/kg (55 mg) po/day, and folate 5 mg PO/day.