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Why does this woman have joint pain and a swollen neck?

This woman was worried she had rheumatoid arthritis. Dr Hercules Robinson describes how a delayed symptom suggested otherwise


The patient

This middle-aged woman had a history of recurring joint pain, affecting her knuckles, wrists, elbows, ankles and knees. But the pain was mild and not associated with any swelling or stiffness. There were no systemic features. She did, however, complain of fatigue.

Her past history was uncomplicated and she was on no regular medication. There was no family history of rheumatoid arthritis but a friend of hers had been diagnosed with RA and she was worried that she had developed the same disease.

First instinct

Despite the lack of morning stiffness and swelling, I wondered whether she was right and had mild RA.

Differential diagnosis

• Rheumatoid arthritis

• Osteoarthritis

• Other connective tissue arthropathies such as SLE, Sjogren's syndrome

• Arthropathy associated with inflammatory bowel disorder

• Gout – unlikely

Getting on the right track

General examination was unremarkable.

Her musculoskeletal system was normal on examination – there was no joint swelling, the knuckles were sharply demarcated on making a fist and her grip strength was normal.

There were no oral or eyes signs. She had no GI symptoms and her abdomen was normal.

I arranged some routine blood tests. Her full blood count was normal, with no evidence of mild anaemia typical of RA. Her liver, renal and thyroid function was normal. Her rheumatoid factor was negative as was her auto-antibody screen. Her C-reactive protein was normal but her ESR was slightly elevated at 42mm/hr.

An X-ray of her hands showed no erosions or evidence of arthritic changes.

I prescribed simple analgesia and told her that the rheumatoid tests were all normal. Her symptoms were controlled with this and the plan was to manage her symptomatically.

The hidden clue

She subsequently came to see me as she had developed facial swelling. On examination, she had smooth non-tender swellings of both parotid glands.

About one-third of patients with Sjogren's syndrome develop symptoms of arthritis, and one-third can develop salivary gland enlargement. Blood tests revealed an anti-nuclear antibody profile typically seen in Sjogren's, SSB/La and SSA/Ro.

She was reassured that she finally had a diagnosis. She went on to develop a dry mouth (xerostomia) and dry eyes (keratoconjuctivitis sicca).

She was managed with ocular and oral lubricants as well as simple analgesia.

The disease is usually benign and associated with a normal lifespan. A small percentage of patients, however, do develop lymphoma.

Dr Hercules Robinson is a GP in Caithness

Why does this woman have joint pain and a swollen neck? Why does this woman have joint pain and a swollen neck?

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