From the Guidelines
The most appropriate diagnostic study to perform next is radiography of the hands and feet. This patient presents with symptoms consistent with early rheumatoid arthritis (RA), including morning stiffness, bilateral symmetric joint pain affecting small joints of hands and feet, and a positive anti-CCP antibody test, which is highly specific for RA. According to the 2013 EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis 1, radiography of the hands and feet should be used as the initial imaging technique to detect damage.
The patient's clinical presentation, including mild bilateral tenderness of the carpal, metacarpophalangeal, and proximal interphalangeal joints, as well as mild bilateral tenderness of the metatarsophalangeal and tarsal joints, is consistent with early RA. The positive anti-CCP antibody test further supports this diagnosis, as it is highly specific for RA. While the patient has a negative rheumatoid factor, approximately 20% of RA patients can be seronegative, and the positive anti-CCP antibody strongly supports the diagnosis.
The 2018 ACR Appropriateness Criteria for chronic wrist pain 1 and the 2017 EULAR recommendations for the management of early arthritis 1 also support the use of radiography as the initial imaging study for suspected RA. These guidelines emphasize the importance of early radiographic assessment in confirming the diagnosis and establishing a baseline for monitoring disease progression.
Key points to consider in this case include:
- The patient's symptoms are consistent with early RA
- The positive anti-CCP antibody test is highly specific for RA
- Radiography of the hands and feet is the initial imaging study of choice for suspected RA
- Early radiographic assessment is crucial for timely diagnosis and treatment initiation to prevent irreversible joint damage and disability.
From the Research
Diagnostic Approach
The patient presents with symptoms of worsening fatigue and joint pain, which are constant but worse in the morning. The physical examination reveals mild bilateral tenderness of various joints and slight restriction in the range of motion of the ankles. Laboratory studies show an elevated erythrocyte sedimentation rate, negative rheumatoid factor, and positive anticyclic citrullinated peptides.
Next Diagnostic Step
Given the patient's symptoms and laboratory results, the most appropriate diagnostic study to perform next is:
- D. radiography of the hands and feet This is supported by studies 2, 3, which highlight the importance of conventional radiography in diagnosing and monitoring rheumatoid arthritis. Radiography of the hands and feet can help assess joint damage and progression, and is a valuable tool in differentiating between rheumatoid arthritis and other arthritides.
Rationale
The presence of anti-CCP antibodies is associated with a higher risk of radiological joint damage and progression 4, 5. The patient's positive anti-CCP result suggests a high likelihood of rheumatoid arthritis, and radiography of the hands and feet can help confirm this diagnosis. Additionally, study 3 found that radiographing both hands and feet provides more comprehensive information than radiographing only one or the other.
Alternative Options
The other options are not supported by the evidence as the next best diagnostic step:
- A. anti-double-stranded DNA test: not directly relevant to the patient's symptoms and laboratory results
- B. joint fluid analysis: may be considered if there is suspicion of joint infection or crystal arthropathy, but not as the next step in this case
- C. PET scan: not typically used in the diagnosis of rheumatoid arthritis
- E. synovial biopsy: may be considered in certain cases, but not as the next step in this case