Question 10.3
With reference to the image depicted below:
a) What is the diagnosis?
b) List three characteristic signs of your diagnosis shown in the image.
c) List three abnormalities that may be seen on chest XRay in this condition
College Answer
- a) Rheumatoid arthritis.
- b) Ulnar deviation:
- Z deformity of the thumb
- Boutonnieres deformity (left little finger)
- Swan neck deformity (right middle and ring fingers)
- Swelling of metacarpo-phalangeal joints
- Wasting of small muscles of the hand
- c) Pleural effusion:
- Pleural thickening.
- Nodules.
- Interstitial fibrosis.
- Bronchiectasis.
- Skeletal rheumatoid changes e.g. shoulder arthritis.
- Caplan’s syndrome in patients with pneumoconiosis.
20
Discussion
The free-to-use image displayed above is not the image from the CICM paper, but a picture of rheumatoid arthritis hands from a Wikipedia article.
The following physical signs are still obvious:
- Ulnar deviation
- Z deformity of the thumb
- Swan neck deformities (middle image)
- Swelling of metacarpo-phalangeal joints
- Wasting of small muscles of the hand (right image)
- Boutonnieres deformity is not obvious, but is probably present in the right image
In general, the clinical features of rheumatoid arthritis include the following:
- Symmetric joint swelling, MCP > DIP
- Morning stiffness lasting at least 1 h before maximal improvement
- Extra-articular synovitis (tenosynovitis, bursitis)
- General symptoms (malaise, fatigue, weight loss, fever)
- Hand signs as mentioned above:
- Ulnar deviation
- Z deformity of the thumb
- Swan neck deformities
- Swelling of metacarpo-phalangeal joints
- Wasting of small muscles of the hand
- Boutonnieres deformity
The site clinicalexam.com has an excellent entry on RA, with extensive lists of signs and examination techniques.
Pulmonary involvement in rheumatoid arthritis tends to manifest in the following ways:
- Pleurisy/pleural effusion
- Pneumothorax
- Rheumatoid nodulosis
- Interstitial pulmonary fibrosis
- Caplan's syndrome is the combination of rheumatoid nodules and pneumoconiosis
- Bronchiectasis
- Pulmonary vasculitis
- Methotrexate-induced interstitial pulmonary fibrosis
References
Talley and O'Connor is a good source for the clinical features of RA.
Arnett, Frank C., et al. "The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis." Arthritis & Rheumatism31.3 (1988): 315-324.
Anaya, Juan-Manuel, et al. "Pulmonary involvement in rheumatoid arthritis."Seminars in arthritis and rheumatism. Vol. 24. No. 4. WB Saunders, 1995.
Grassi, Walter, et al. "The clinical features of rheumatoid arthritis." European Journal of Radiology 27 (1998): S18-S24.
Krane, S. M., and L. S. Simon. "Rheumatoid arthritis: clinical features and pathogenetic mechanisms." The Medical clinics of North America 70.2 (1986): 263-284.