A 62‐year‐old man with wrist and hand pain

Abstract

A 62-year-old man presented to the rheumatology clinic with report of bilateral wrist and hand pain. His symptoms had begun several months before, and over the preceding 2 months had become so severe that he was unable to make a fist. The patient observed that he had begun "walking like an old man" and had difficulty getting out of his car. His joint symptoms were associated with morning stiffness of more than 1 hour. The patient also reported swelling in his hands and wrists. Past medical historyHis past medical history was notable for hypertension, hypercholesterolemia, prostatic hypertrophy, and fractures of the left tibia and fibula, which he had sustained in a skiing injury. Previous surgeries had included a vasectomy, removal of a basal cell cancer from his nose, and bilateral carpal tunnel release 2 years before presentation.In addition, for at least 5 years, the patient had had persistent arthralgias of his shoulder and knees. He had taken ibuprofen, with some improvement. However, the medication caused lower extremity edema and was discontinued. He then began celecoxib.The patient believed that his shoulder symptoms had been precipitated by lifting weights. He had undergone bilateral shoulder arthroscopies within 1 year of his presentation and received the diagnosis of degenerative joint disease. At arthroscopy, the patient had undergone debridement of both glenohumeral joints, as well as the reattachment of a torn left glenoid labrum. The operative report had indicated an unremarkable synovium.Six months before presentation, the patient had developed chest pain without electrocardiogram changes. A cardiac catheterization had shown normal coronary arteries, and his symptoms were ascribed to gastroesophageal reflux. He had noted occasional bright red blood per rectum and dark stools. A colonoscopy 2 years before presentation had shown sigmoid diverticulosis and non-bleeding external hemorrhoids.The patient's medications upon presentation to the rheumatology clinic were aspirin (81 mg/day), terazosin hydrochloride (5 mg at bedtime), carvedilol (20 mg/day), and celecoxib (100 mg twice daily). He had no known drug allergies. Social and family historyThe patient was a real estate developer. He lived with his wife and 2 children. He did not smoke and drank alcohol less than 1 to 2 times a week. Review of systemsThe patient denied skin rash, photosensitivity, alopecia, oral ulcers, weight loss, numbness or tingling in the extremities, and focal motor weakness. He also denied headaches, jaw claudication, vision changes, fevers, and cough. Physical examinationThe patient was afebrile, with a blood pressure of 124/70 mm Hg and a pulse of 80 beats/minute. His pulmonary, cardiac, and abdominal examination results were normal. There were no rashes or skin lesions. However, he had boggy swelling of his bilateral proximal interphalangeal and metacarpophalangeal joints and wrists. The areas were painful to palpation, with minimal warmth and no overlying erythema. Flexion and extension in the wrist were limited by pain....

Shoulder Pad Sign and Asymptomatic Hypercalcemia in a Patient with End-Stage Kidney Disease

“…Polyarticular swelling associated with stiffness and a diminished range of motion is recognized to be a characteristic symptom of rheumatoid arthritis. 23,24 Although the prevalence of this physical sign may be minor, it can be a diagnostically significant manifestation in some subsets of patients with AL amyloidosis caused by MM. [25][26][27] Indeed, previous reports contain several references to the occurrence of multiple-joint swelling in association with MM, drawing attention to the fact that such manifestations may be attributed to the onset of AL amyloidosis mediated by the infiltration of amyloid proteins to the dependent portion of the skeletal and periarticular structures.…”