QD 71 - Seronegative RA Save
QD Clinic - Lessons from the Clinic
Musings on Seronegative RA
Transcription
This is QD clinic, and I'm doctor Jack Cush of RheumNow. QD clinic is brought to you by rheumnow.live. Keen minds need great meetings like this, rheumnow.live. Today's case, seronegative room rheumatoid arthritis. 45 year old woman presents with a six month history of polyarthralgias, morning stiffness, and said to have some abnormal labs.
On exam, she has 12 tender joints, symmetric polyarthritis. Five of them are swollen, two plus so even warm, and she's unable to close her hands. She has a C. Dye score of 25. We put her on 10 of prednisone and hydroxychloroquine, we get labs.
Labs come back somewhat disappointing. Normal sed rate, sorry. CRP was elevated. Sed rate was not. CRP was, like, 12.
ASO, ACE levels, other labs, ANA, rheumatoid factor, CCP, fourteen thirty three eta, all negative. Upon further questioning, she has had a carpal tunnel in the past. She has not responded to the therapies we gave her. She comes in a month later, and she's doing really poor. The only thing we did find on lab tests besides a somewhat elevated CRP was that she had marginal elevations of LFTs.
She herself is a little overweight. Someone told her she's had LFTs in the past. Fatty liver, I don't know. But nonetheless, the question is, what does this gal have? She has a seronegative, but nonetheless polyarthritis not responding to conventional medicines at four or six weeks.
And so what do we do? Well, we put her on etanercept in addition to the hydroxychloroquine and ten to fifteen milligrams of prednisone. We managed her pain with QHS analgesics, and we labeled her a seronegative RA. The question is, is that the right label? I think it's a label that's the right one for now.
You bear that label when you meet the criteria for rheumatoid arthritis, and she does having both small and large joints, by having an acute phase reactant, having synovitis for a long enough period of time. Obviously, you get there a lot faster as far as criteria if you have a CCP antibody and a rheumatoid factor sheath is not. I think the designation of seronegative RA is important. To have that diagnosis, you actually have to have a lot of features of RA and still be seronegative to qualify as having RA. Two, it's borne out over time, so chronicity sort of verifies and solidifies the diagnosis.
However, there is no proof that over time that you're safer in that diagnosis. In fact, over time, a significant minority of these patients will evolve into another well identified syndrome, Whipple's disease, or IBD, or psoriatic arthritis, or Lord knows what. What we do know is that chronicity of swelling and pain, meaning more than twelve weeks of swelling and pain, makes you likely to have an inflammatory arthritis. You're never fully going to be called rheumatoid for certain while you're seronegative. And I think the point that I want to stress is that being seronegative is your opportunity to rethink the diagnosis at every visit.
I'm a little concerned about this particular patient's LFT elevations, so we are ordering things like an ANCA and anti mitochondrial antibodies, anti smooth muscle antibodies, and getting a liver consult for them to look at her because if she has persistent liver enzyme elevations, they may want to do more than just ultrasound to see the size of a liver and whether it's echogenic and has signs of steatosis. So, again, surrogate was a big challenge because you never quite know and will she respond? Well, didn't respond to Plaquenil and Prednisone, pretty high dose. We'll see if she responds to etanercept and then over time, non response further questions the diagnosis of seronegative RA. That's it for this edition of QD Video.
Tune in tomorrow.
On exam, she has 12 tender joints, symmetric polyarthritis. Five of them are swollen, two plus so even warm, and she's unable to close her hands. She has a C. Dye score of 25. We put her on 10 of prednisone and hydroxychloroquine, we get labs.
Labs come back somewhat disappointing. Normal sed rate, sorry. CRP was elevated. Sed rate was not. CRP was, like, 12.
ASO, ACE levels, other labs, ANA, rheumatoid factor, CCP, fourteen thirty three eta, all negative. Upon further questioning, she has had a carpal tunnel in the past. She has not responded to the therapies we gave her. She comes in a month later, and she's doing really poor. The only thing we did find on lab tests besides a somewhat elevated CRP was that she had marginal elevations of LFTs.
She herself is a little overweight. Someone told her she's had LFTs in the past. Fatty liver, I don't know. But nonetheless, the question is, what does this gal have? She has a seronegative, but nonetheless polyarthritis not responding to conventional medicines at four or six weeks.
And so what do we do? Well, we put her on etanercept in addition to the hydroxychloroquine and ten to fifteen milligrams of prednisone. We managed her pain with QHS analgesics, and we labeled her a seronegative RA. The question is, is that the right label? I think it's a label that's the right one for now.
You bear that label when you meet the criteria for rheumatoid arthritis, and she does having both small and large joints, by having an acute phase reactant, having synovitis for a long enough period of time. Obviously, you get there a lot faster as far as criteria if you have a CCP antibody and a rheumatoid factor sheath is not. I think the designation of seronegative RA is important. To have that diagnosis, you actually have to have a lot of features of RA and still be seronegative to qualify as having RA. Two, it's borne out over time, so chronicity sort of verifies and solidifies the diagnosis.
However, there is no proof that over time that you're safer in that diagnosis. In fact, over time, a significant minority of these patients will evolve into another well identified syndrome, Whipple's disease, or IBD, or psoriatic arthritis, or Lord knows what. What we do know is that chronicity of swelling and pain, meaning more than twelve weeks of swelling and pain, makes you likely to have an inflammatory arthritis. You're never fully going to be called rheumatoid for certain while you're seronegative. And I think the point that I want to stress is that being seronegative is your opportunity to rethink the diagnosis at every visit.
I'm a little concerned about this particular patient's LFT elevations, so we are ordering things like an ANCA and anti mitochondrial antibodies, anti smooth muscle antibodies, and getting a liver consult for them to look at her because if she has persistent liver enzyme elevations, they may want to do more than just ultrasound to see the size of a liver and whether it's echogenic and has signs of steatosis. So, again, surrogate was a big challenge because you never quite know and will she respond? Well, didn't respond to Plaquenil and Prednisone, pretty high dose. We'll see if she responds to etanercept and then over time, non response further questions the diagnosis of seronegative RA. That's it for this edition of QD Video.
Tune in tomorrow.
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