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JAMA Dermatology Clinicopathological Challenge
April 2017

Swollen Hand Joints With Asymptomatic Nodules on the Skin

Author Affiliations
  • 1Department of Dermatology, Peking University First Hospital, Beijing, China
JAMA Dermatol. 2017;153(4):313-314. doi:10.1001/jamadermatol.2016.4261

A man in his 40s presented with gradual hair loss of the eyelashes, eyebrows, beard, and scalp for 4 years, swelling and painful hand joints for 13 months, and multiple asymptomatic nodules on the upper arms for 40 days. The patient exhibited no associated fever, analgesia or hypesthesia. He reported no previous infections or family or personal medical history of autoimmune diseases or psoriasis. He was previously treated for rheumatoid arthritis, but various arthritis treatments showed no improvements over 1 year. A physical examination showed diffuse infiltration of the face with loss of skin creases and diminished facial hair; all joints of both hands were swollen (Figure, A); multiple asymptomatic nodules without ulceration were present on his upper arms (Figure, B); decreased sensation to pain, temperature and/or touch and neuropathic changes were not found. Laboratory test results showed a slightly elevated erythrocyte sedimentation rate (27 mm/h) and significantly elevated rheumatoid factor (70.1 IU/mL). Additional immunology indicators, including C-reactive protein, anticyclic citrullinated peptide, antinuclear antibodies, and globulin levels were normal. X-ray and joint ultrasound results suggested osteoarthritis, synovitis, flexor tendon tenosynovitis, and bone erosions. Ultrasound results also indicated enlarged axillary, cervical, and inguinal lymph nodes and an enlarged spleen. Fundus fluorescein angiography showed uveitis.

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