A CASE OF EROSIVE SEROPOSITIVE RHEUMATOID ARTHRITIS WITH RHEUMATOID NODULES AND DIGITAL VASCULITIC ULCER

*Avijit Saha and Parna Roy

ABSTRACT

A 40 years old female patient of known Rheumatoid arthritis for last 6 years presented with severe debilitating joint pain, swelling and restriction of movement in her small joints of hands, feet, both ankles and knees for last few months. She also had multiple ulcers over knuckles and fingers of both hands[Figure 1] and one medium sized ulcer over lateral malleolus of right foot with occasional discharge from ulcer sites [Figure4]. She also reported tingling, numbness sensation over her hands and feet. Her medical history revealed that she used to take over the counter drugs for her relapsing-remitting pain but no definitive treatment she had ever received. Examination revealed tenderness, swelling, limitation of movement of bilateral wrists, Metacarpophalangeal (MCP), Proximal Interphalangeal(PIP), metatarsophalangeal joint (MTP), ankle and knee joints. There was mild ulnar deviation of MCP joints of both hands and hyperextension of PIP joints and flexion of the DIP joints of right middle,ring fingers - that kind of deformity is described in literature as "Swan neck deformity"[Figure1]. There was flexion of PIP joints and hyperextension of DIP joints of four fingers of left hand; and index finger of right hand; and that is classically described in literature as "Boutonniere deformity"[Figure 2]. The thumb of both hands were flexed at MCP joints and hyperextended at interphalangeal joints what is called "Z deformity of the thumb" [Figure 3].Patient also had multiple painful ulcerated lesions in the dorsum of finger and one medium sized Grade II ulcer over lateral malleolus of right foot[Figure 4]. We also noticed few localised non tender nodular swelling over the fingers that are consistent with Rheumatoid nodules and some of them were ulcerated also. Laboratory tests revealed elevated Erythrocyte Sedimentation Rate(ESR), C-Reactive Protein (CRP), platelet count. Hemogram revealed Anaemia of Chronic disease. Serological test were positive for RA factor, anti-cyclic citrullinated peptide (anti-CCP) and negative for any antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA) and cryoglobulins. Radial and Ulnar arteries were clear in USG- Doppler study at wrist. Lower Limbs ABPI (Ankle Brachial Pressure index) were calculated and found to be 0.9 in both limbs. Hand X-ray showed radiographic signs consistent with rheumatoid arthritis. Biopsy was taken from Lateral malleolus ulcer site and revealed signs of chronic inflammation; discharge culture showed no growth. Clinico-laboratory and radiographic findings taken together: Rheumatoid Arthritis activation with severe deformities with vasculitic ulcers and Rheumatoid nodules, diagnosis was made.

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