Multiple joint dislocations and bone disintegration in rheumatoid arthritis: A case report

Rheumatoid arthritis (RA) is a chronic inflammatory disease, which typically affects the small joints of the hands and feet. Anti-rheumatism drugs should be promptly administered upon a diagnosis. Without standardized treatment, patients are prone to different degrees of deformities in the later stages of disease development, which negatively impact quality of life.

The patient was a 52-year-old Chinese woman with an 18-year history of RA complaining of pain and swelling in both shoulders, and in the elbows, wrists, proximal interphalanges (PIP), hips, knees, and ankles. Morning stiffness persisted for over 1 hour. As the disease progressed, the MCP & PIP gradually became increasingly deformed, and the muscle strength in the limbs gradually decreased. The patient had been self-medicating with large and irregular doses of dexamethasone and amoxicillin for pain relief; however, the treatment was ineffective. Patient intermittently self-medicated with leflunomide and methotrexate.

On physical examination, the shoulders, elbows, wrists, PIP, hips, knees, and ankles were swollen and tender to palpation with decreased ROM suggestive of synovitis of the joints. The patient suffered from deformity of the MCP and PIP joints. The left upper limb muscle strength was grade 3, right upper limb - grade 2, left lower limb - grade 4, right lower limb - grade 2, and the limb muscle tone was decreased.

Laboratory tests showed an ESR of 70 mm/h, serum anti-CCP level of 171.45 RU/mL (normal 0–20 RU/mL), serum rheumatoid factor (RF) level of 108 U/L (normal 0–18 U/L), and CRP level of 82.54 mg/L (normal 0–10 mg/L), whereas all other biochemical parameters were within the normal range.

Her Disease Activity Score of 28 joints - ESR (DAS28-ESR), Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) were 6.2, 38.254, and 30 respectively.

X-rays of the bilateral shoulders, hands, and feet showed RA in the bilateral shoulder joints with dislocation of the right shoulder joint and subluxation of the left shoulder joint. Similarly, bilateral hands and feet X-rays showed multiple joint subluxation and joint deformities. The combined clinical, laboratory, and X-ray findings were consistent with a diagnosis of RA.

Treatment commenced immediately with a combination of technetium methyl diphosphonate injections, methotrexate (10 mg, orally weekly), and tofacitinib (10 mg, orally daily). The patient also received a methylprednisolone sodium succinate injection of 40 mg after 3 days of intravenous drip reduced to 20 mg and continued infusion for 3 days before switching to oral medication for maintenance.

According to the evaluation of the disease activity of RA, the treatment regimen resulted in clinical improvement, as demonstrated by reduced pain and swelling in the joints. After discharge, the authors administered as maintenance therapy tofacitinib (10 mg, orally daily), methotrexate (10 mg, orally weekly), folic acid tablets (10 mg, orally weekly), methylprednisolone (8 mg, orally daily), and pantoprazole enteric capsules (40 mg, orally daily).

In the first follow-up consultation, the joint pain had dramatically decreased. The results from laboratory tests were normal, including CRP (0.76 mg/L) and ESR (17 mm/h) levels. However, the RF level (98 U/L) remained high. Her DAS28-ESR, SDAI, and CDAI were 3.5, 15.076, and 15, respectively, significantly lower than before.

The authors concluded that – “To prevent joint deformities, patients with RA need to be vigilant and informed about the disease, and must seek out a consultation once symptoms arise to obtain an accurate diagnosis and appropriate treatment as soon as possible. Physicians should apply available advanced technologies to enable the early diagnosis and treatment of RA, provide health education to patients, emphasize the importance of RA and treatment of the primary disease, improve patient treatment and medication adherence, and schedule regular followups after discharge. Patients should be instructed to return to the clinic regularly and to seek an appointment with a doctor should they experience any discomfort. Early detection, diagnosis, and treatment can prevent the occurrence of joint diseases. Through this case report, we expect to increase the knowledge and diagnostic awareness of clinicians regarding this disease.”

Further reading:

Multiple joint dislocations and bone disintegration in rheumatoid arthritis: A case report Xuemei Yuan, Feng Luo et al International Journal of Rheumatic Diseases 2022; 00:1–4. DOI: 10.1111/1756-185X.14549