LIVERPOOL, ENGLAND — All patients with newly diagnosed rheumatoid arthritis should have a chest x-ray to rule out rare conditions that can cause arthralgias and inflammation.
Dr. Sarah E. Medley based this advice on a case in which a 52-year-old woman with a 45 pack-year history of smoking presented to the orthopedics department of Queen Elizabeth Hospital, Woolwich, England, with arthralgias affecting the knees, shins, and wrists. Although synovial biopsy of the right knee revealed no synovitis, the patient was diagnosed with rheumatoid arthritis (RA) and treated with methotrexate and then sulfasalazine with prednisone and intramuscular corticosteroids. She was subsequently given an additional diagnosis of facet joint arthritis and given tramadol, meloxicam, and gabapentin for pain.
Rheumatoid factor was negative and erythrocyte sedimentation rate rose from 27 to 101 mm/h, while the woman's disease activity score was very high, at 8.2.
Because conventional treatment was unsuccessful, anti-tumor necrosis factor therapy was planned. Only then was a chest x-ray ordered—as is needed to rule out tuberculosis in patients embarking on biologic therapy. The x-ray revealed a large right apex mass that proved to be a squamous cell carcinoma of the lung. Subsequent resection resulted in rapid and significant improvement in the patient's articular symptoms, and other medications—except analgesics—were stopped because she was receiving adjuvant chemotherapy, Dr. Medley wrote in a poster presented at the annual meeting of the British Society for Rheumatology.
“This case illustrates the need for a chest x-ray in new RA, and emphasizes the fact that atypical unresponsive RA requires review of the diagnosis rather than just treatment escalation,” Dr. Medley wrote.