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Case 3

3e Initiative 2009 How to investigate and follow-up Undifferentiated Peripheral Inflammatory Arthritis?. Case 3. Case 3.

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Case 3

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  1. 3e Initiative 2009How to investigate and follow-up Undifferentiated Peripheral Inflammatory Arthritis? Case 3

  2. Case 3 • Victoria is a 21 year old student. She presents with arthralgias of 4 weeks, no early morning stiffness, no decrease function. She has no history of exposure to infections, fever or recent trauma. You examine her and find a tender right wrist, tender MTP’s. Swelling in right first PIP. You order the following tests: ESR , CRP, CBC, all of which are normal.

  3. Question 1 • What additional laboratory tests would be helpful to predict whether she will develop RA? • RF • ANA • ACPA • ANCA • ENA

  4. Question 1 • What additional laboratory tests would be helpful to predict whether she will develop RA? • RF • ANA • ACPA • ANCA • ENA

  5. Recommendation 4 • Testing of RF and/or ACPA should be performed in the evaluation of patients with UPIA, as these factors are predictive of RA diagnosis and prognosis; negative tests do not exclude progression to RA [1a, A]. If a connective tissue disease / systemic inflammatory disorder is suspected, additional autoantibody tests should be considered [5, D].Agreement: 9.05/10

  6. Question 2 • You give her a trial of NSAIDS, when should you see her again and what particular features on history and physical should you document to help you make a diagnosis? • 2 weeks • 6 weeks • 10 weeks • Duration of morning stiffness • Pattern of joint synovitis

  7. Answer Question 2 • You give her a trial of NSAIDS, when should you see her again? • 2 weeks • 6 weeks • 10 weeks

  8. Recommendation 9 • Predictors of persistent inflammatory arthritis should be documented and include disease duration of ≥6 weeks [1b, A], morning stiffness >30 min [4, C], functional impairment [4, C], involvement of small joints [4, C] and/or knee [4, C], ≥ 3 joints [1b, B], ACPA [4, C] and/or RF positivity [4, C] and presence of radiographic erosion [1b, B]. Agreement: 8.59/10

  9. Question 3 • She now reports increased pain in her feet, difficulty in walking, early morning stiffness of 60 minutes, increased fatigue. On exam, she now has swelling of her fore feet. You perform x-rays of her hands and feet which are normal. Long term prognosis unknown. • What test(s) would you order? • Ultrasound of wrist(s) • MRI of hand(s) • x • x

  10. Answer Question 3 • She now reports increased pain in her feet, difficulty in walking, early morning stiffness of 60 minutes, increased fatigue. On exam, she now has swelling of her fore feet. You perform x-rays of her hands and feet which are normal. Long term prognosis unknown. • What test(s) would you order? • Ultrasound of wrist(s) • MRI of hand(s) • x • x

  11. Recommendation 6 • There is insufficient evidence to recommend the routine use of MRI and US for diagnosis or prognosis in UPIA [5, D]; in UPIA and suspicion of RA, MRI of hands and wrists could be considered for diagnosis [2b, B]Agreement: 8.22/10

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