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.