Gene/Protein Disease Symptom Drug Enzyme Compound
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The history of classification and diagnostic criteria for rheumatoid arthritis (RA) and ankylosing spondylitis (AS) is similar and different. Important criteria sets have been published for both disease in the mid eighties, for AS in 1984 and for RA in 1987. The leading clinical symptoms, inflammatory back pain (IBP) in AS and the predominant polyarticular symmetric involvement of the hands in RA were, of course, central, and so was morning stiffness as a major clinical sign of an inflammatory disease state. In RA, there was more focus on laboratory parameters (rheumatoid factor), while this could have been the case also in AS (HLA B27) but this was not recognized at this point in time. In contrast, imaging has played a more important role in AS - especially because the sacroiliac joints are involved in the vast majority of AS patients, while in RA radiographic changes of the joints of hands and feet may contribute to the diagnosis. However, in both diseases, early structural changes visualized by conventional radiography rather have prognostic impact since these patients are much more likely to progress in comparison to others who do not have cartilage and joint damage early in the course of the disease. Further developments of criteria for AS have broadened the spectrum of AS to spondyloarthritis (SpA) and axial SpA which covers most early forms. The leading clinical symptom is chronic back pain in young adults and IBP. New criteria for RA which include more patients with early disease and anti-CCP antibodies as new markers are being developed. This is important since early treatment strategies are increasingly and successfully used to treat inflammatory diseases more efficiently.
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PMID:Classification criteria for rheumatoid arthritis and ankylosing spondylitis. 1982 49

A 48-year-old male presented to the emergency room for 2 weeks of joint pain and swelling of his four extremities. His symptoms started suddenly and were quite debilitating. His hands, fingers, knees, and ankles were so swollen and painful that he was unable to get out of bed and had to use crutches to ambulate. He also complained of anorexia, nausea, and lack of energy over the past few months, but denied any other complaints. His only medical history was a traumatic left tibia fracture 1 year ago. The patient had a 30-pack year history of smoking tobacco and used marijuana daily. The patient recently had an arthrocentesis at an outside hospital which was non-diagnostic and showed no infection. Given his symptoms, a thorough rheumatic workup was ordered. The ESR and CRP were elevated. ANA, rheumatoid factor, HLA B27, HIV, hepatitis panel, TSH, T4, Coombs antibodies, gonorrhea, chlamydia, CCP, alpha 1 antitrypsin, parvovirus, fungal antibodies, and myeloperoxidase antibodies were all within the normal range. X-rays of the hands, knees, and ankles were ordered. The images showed diffuse joint swelling with no fractures, dislocations, or hardware mispositioning. It also showed tissue swelling in the fingers that could not exclude hypertrophic pulmonary osteoarthropathy. A chest x-ray revealed a large 8.5 cm oval mass in the right upper lobe. A follow-up CT revealed a massive right upper lobe lung mass concerning for malignancy versus fungal etiology. A CT guided biopsy of the mass was performed and revealed a poorly differentiated non-small-cell lung cancer, favoring adenocarcinoma. Further CT imaging revealed limited stage disease. During the hospitalization, the patient was provided with NSAIDs for his joint pain, which provided minimal benefit. There was little to no improvement in his joint swelling. Oncology was consulted and further evaluation in the outpatient setting was recommended to determine if he would be a surgical candidate and/or to decide the best chemotherapeutic regimen. This case demonstrates an unusual presentation of non-small-cell lung cancer and highlights the importance of maintaining malignancy on the differential diagnosis for sudden arthritis.
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PMID:Sudden onset polyarthritis as a paraneoplastic syndrome from non-small cell lung cancer. 3285 61