Case 4: Diagnosis and Conclusions

Case Published: November 2022

Author: Stacy Bagrova, MD (@asbagrova)

Case editor: Jeffrey Sparks, MD (@jeffsparks)

Diagnosis: Highly seropositive non-erosive rheumatoid arthritis

Case Summary:

Our patient is a young woman with symmetric inflammatory polyarthritis of both hands lasting for 3 months. Her exam confirms polyarticular swelling and tenderness in multiple small joints of hands. Basic labs demonstrate acute inflammation: anemia, thrombocytosis, elevated inflammation markers. Serologic studies confirm high tiers of RF and CCP. X-rays are so far unaffected by inflammatory changes, which correlates with the recent onset of her disease. This establishes the diagnosis of rheumatoid arthritis (RA). The fact that she has recently delivered a baby may also be important. Studies show an increased incidence of RA in the first 6 months post-partum. If you’d like to learn more about why this happens, check out this review article (1).

RA is a type of chronic inflammatory arthritis. It is more common in women with average age of onset in 5th or 6th decade. Typical joints affected include small joints of hands – MCPs, PIPs, carpal bones, wrist. Larger joints such as shoulders, elbows, knees, ankles can also be affected but usually after small joints. Although, patients do not read books, so absence of small joint involvement does not necessarily exclude this Dx. We expect swelling in affected joints and AM stiffness > 30 min and usually > 1 hour. In contrast, osteoarthritis usually presents with bony enlargement in PIP and DIP joints, has stiffness < 30 min in duration. OA tends to affect weight bearing joints: knees, MTPs (note that ankle is a hinge-joint, not a weight bearing joint) and overused joints (e.g., shoulders in baseball players). Lumbar and thoracic spine are usually not affected in RA. Check out our arthritis schema and inflammatory arthritis schema (coming soon!) for more information on DDx.

There are several genetic factors associated with development of RA. Environmental triggers, such as bacteria and viruses, have been implicated as well. An important modifiable risk factor to remember is smoking. The risk of RA is increased two-fold in men who smoke and 1.3-fold in female smokers compared with non-smokers (3).

It is important not to neglect extra-articular manifestations of RA: inflammatory eye disease (episcleritis, scleritis), pulmonary involvement (ILD, nodules, pleuritis, bronchiolitis obliterans, bronchiectasis), cardiac (CAD, nodules on valves, pericarditis, myocarditis), skin (subcutaneous nodules, vasculitis), blood (Felty’s, LGL, lymphoma), neurologic (peripheral neuropathy, nerve entrapment, vasculitis –> mononeuritis multiplex), secondary Sjogren’s, osteoporosis, amyloidosis, etc.  Patients who are highly seropositive as well as male patients are more likely to develop extra-articular disease (4).

The intricacies of treatment of rheumatic diseases are beyond the scope of this educational tool but if you are interested, ACR recently released updated treatment guidelines for RA (5). It is very important to remember that patients on immunosuppressive medicines are at higher risk of infections, so make sure they are fully vaccinated (including against COVID, pneumonia, herpes zoster, influenza) and do not discount the possibility of infection simply based on the absence of fever. RA-affected joints are also more likely to get septic arthritis.

Early diagnosis of RA is very important for patient outcomes. Development of irreversible life-limiting joint changes and extra-articular manifestations can be prevented with early diagnosis and treatment. Refer these patients early to your friendly neighborhood rheumatologist to start treatment as soon as possible. Make sure to encourage smoking cessation, exercise, and aggressive cardiovascular risk prevention.


1. Østensen, M., Villiger, P. M., & Förger, F. (2012). Interaction of pregnancy and autoimmune rheumatic disease. Autoimmunity reviews11(6-7), A437-A446.

2. Aletaha D, Smolen JS. Diagnosis and Management of Rheumatoid Arthritis: A Review. JAMA. 2018;320(13):1360–1372. doi:10.1001/jama.2018.13103. 

3. Sugiyama, D., Nishimura, K., Tamaki, K., Tsuji, G., Nakazawa, T., Morinobu, A., & Kumagai, S. (2010). Impact of smoking as a risk factor for developing rheumatoid arthritis: a meta-analysis of observational studies. Annals of the rheumatic diseases69(01), 70-81.

4. Turesson, C., O’fallon, W. M., Crowson, C. S., Gabriel, S. E., & Matteson, E. L. (2003). Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years. Annals of the rheumatic diseases62(8), 722-727.

5. Fraenkel L, Bathon JM, England BR, St Clair EW, Arayssi T, Carandang K, Deane KD, Genovese M, Huston KK, Kerr G, Kremer J, Nakamura MC, Russell LA, Singh JA, Smith BJ, Sparks JA, Venkatachalam S, Weinblatt ME, Al-Gibbawi M, Baker JF, Barbour KE, Barton JL, Cappelli L, Chamseddine F, George M, Johnson SR, Kahale L, Karam BS, Khamis AM, Navarro-Millán I, Mirza R, Schwab P, Singh N, Turgunbaev M, Turner AS, Yaacoub S, Akl EA. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jul;73(7):924-939. doi: 10.1002/acr.24596. Epub 2021 Jun 8. PMID: 34101387; PMCID: PMC9273041.

Case 4 Index
Case 4 Introduction
Case 4 Review of Systems
Case 4 Physical Exam
Case 4 Differential Diagnoses
Case 4 Diagnostic Testing
Case 4 Additional Diagnostic Testing