Rheumatoid arthritis (RA) is the most common autoimmune joint disease. Tight disease control and major advances in therapy have led to significant improvement in outcomes of this disease. Nevertheless, we came across unusual findings revealing severe consequences of patients’ noncompliance1.
A 66-year-old, right-handed former seamstress with a history of RA since 2006 had started receiving monotherapy with tocilizumab in 2012, but did not show up at our outpatient department for 3 years and had only irregular infusions during that time. Now, she presented with a severe loss of function and pain in hands, knees, and elbows, and an unusually shortened carpal region. Laboratory results showed elevated levels of C-reactive protein (CRP; 2.0 mg/dl), erythrocyte sedimentation rate (56 mm/h), rheumatoid factor (1418 U/ml), and antibodies to citrullinated protein antigens (> 200 U/ml). Arthrosonography revealed strong inflammatory activity. Plain radiographs of both hands showed progressive erosive disease with severe destruction of nearly all joints, especially when compared with radiographs taken 3 years ago (Figure 1A), including a complete lysis of the right and most parts of the left carpus (Figure 1B). Subsequently, we initiated therapy with rituximab (RTX) because of facilitated therapy monitoring and antibody status2. After 4 months, good clinical response was reported. Because CRP levels increased again, the next cycle with RTX was planned. The case illustrates the aggressive character of RA, which can result in destruction of hand joints, especially if not monitored and treated on a regular basis3.
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