Case presentation
A 24 years old male from South Sudan has been referred to our clinic
from the orthopaedics department complaining of bilateral knees swelling
for two years (Fig 1). His condition started with progressive painless
right knee swelling over several months then the left knee was affected
similarly. There was no associated pain, redness or hotness, the
swelling mildly affects his movement, other joints were not affected,
there was no back pain nor morning stiffness, no fever, loss of weight
or other constitutional symptoms. Other systems were unremarkable.
Musculoskeletal examination shows both knees were swollen with effusion
with slight hotness with no tenderness, deformity or restriction of
movements.
Other joints were normal including the back without any muscles weakness
nor tenderness. There are no scalp, skin or nail changes. On general
examination the patient looks well, afebrile, average weight, not pale.
Normal pulse and blood pressure. The patient has no history of diabetic,
hypertensive or any bleeding tendency. he has no history of trauma and
or any family history of rheumatic disease or similar conditions.
General works up is done and shows normal complete blood count
[Blood hemoglobin (13.8 g/dl)( normal value 13.5 to 17.5 g/dl), MCV 75
fl, MCH (28.2 pg), MCHC (37.5 g/dl), WCC (6.900)( Normal value: 4,000
and 11,000 per microliter of blood), platelet: 399,000 (Normal value
50,000 to 450,000 platelets per microliter of blood). ESR is 100 (Normal
value: between 0 and 15 mm/hour), RFT and LFT were both normal, Urine
analysis was also clear, viral screening is negative, rheumatoid factor
(RF) and ACCP were also unremarkable, ANA profile is negative. Chest
X.ray done and also normal. Right knew X.ray (fig 2) and MRI along with
synovial biopsy indicate the diagnosis of rheumatoid arthritis.
Microscopic evaluation of synovial tissue inflammation shows marked
cellular hyperplasia in the lining layer, T-cells, plasma cells,
Macrophages, B-cells, neutrophils, mast cells, NK cells and dendritic
cells accumulate in the synovial sub lining layer. The patient received
prednisolone 20 mg, hydroxychloroquine (HCQ) 200 mg twice daily,
methotrexate 15 mg weekly, folic acid 5 mg twice weekly and osteocare
once daily. One month later the patient frankly improved and swelling
subsided, ESR was 5 mm/hr.