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Why does this woman have painful, swollen joints?

Dr Keith Hopcroft describes how he reached the right diagnosis in this woman with painful, swollen joints.

 

This 65-year-old woman presented with painful, swollen joints in her hands, which had developed over the last few weeks. She routinely took a paracetamol-codeine combination for osteoarthritis of her knee, but said this wasn't really helping her new symptoms. She reported that the swelling seemed permanent, but the pain and stiffness were worse in the morning and after she'd been using her hands. She was otherwise well – her weight was static and her only other medication was a bronchodilator for mild asthma. She was particularly concerned about these new symptoms as she was about to go on holiday.

First instinct

My first thought was that she was developing an inflammatory arthritis – given the relatively recent onset, together with joint swelling and stiffness. Examination revealed a swollen and slightly warm right middle proximal interphalangeal joint, with the same possibly developing on the adjacent ring finger. There was an obvious Heberden's node on the index finger of the same hand. Her other hand seemed less affected, although there seemed to be some proximal interphalangeal joint swelling developing on her left little finger. The joint swellings were slightly warm and very firm. 

 

Differential diagnosis

  • Inflammatory arthritis, for example rheumatoid arthritis
  • Osteoarthritis
  • Gout
  • Ganglions.

This woman had osteoarthritis of her knee, and the presence of a Heberden's node suggested her hand was affected too. But this clinical presentation was much more suggestive of an inflammatory rather than mechanical process.

Gout – as an acute polyarticular attack or in the form of gouty tophi – crossed my mind. But she had no history of previous episodes and the appearance certainly wasn't typical.

A final possibility was ganglions. We do see small ganglions on the hands, especially on the distal interphalangeal joints. But it seemed unlikely that a number would appear at the same time, or that they would cause pain and stiffness.

So I was left with the possibility of an inflammatory arthritis, probably rheumatoid, as the frontrunner, despite some features – such as the asymmetry – being atypical.

 

The hidden clue

I ordered a blood screen, prescribed some anti-inflammatories with PPI cover, and arranged to see her again in a few weeks – after her holiday. I fully expected to arrange a rheumatological referral. But on her return, the blood results were normal and she was delighted to report that – though the swelling remained – the stiffness and pain had completely resolved. This wasn't because of the NSAIDs – despite the PPI, she had suffered dyspepsia and stopped them immediately. So the main symptoms had resolved spontaneously. She was just left with these firm swellings on her proximal interphalangeal joints, which were now starting to make sense.

Getting on the right track

The pattern now pointed towards an acute presentation of osteoarthritis in the hands, sometimes known as nodal arthritis. So these swellings were Bouchard's nodes, which explained why they felt bony, rather than spongy like a synovitis. This was confirmed on review a couple of months later – no pain, obvious Bouchard's nodes and an unconcerned patient.

 

 

Dr Keith Hopcroft is a GP in Laindon, Essex

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