From the Guidelines
For this 39-year-old female with joint pain and elevated inflammatory markers, I recommend a comprehensive rheumatologic workup, including rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP), and imaging studies such as X-rays of the affected joints, as suggested by the 2017 EULAR recommendations for the management of early arthritis 1.
Given her symptoms and laboratory results, the differential diagnosis should consider various forms of inflammatory arthritis, including rheumatoid arthritis (RA) and seronegative spondyloarthropathy. The pattern of joint involvement, affecting small joints of the hands and wrists bilaterally, is concerning for inflammatory arthritis.
The following tests and evaluations are recommended:
- Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (anti-CCP) to assess for RA
- Complete blood count with differential, comprehensive metabolic panel, and uric acid levels to rule out other causes of joint pain and inflammation
- HLA-B27, anti-neutrophil cytoplasmic antibodies (ANCA), and complement levels (C3, C4) to evaluate for other forms of inflammatory arthritis
- Imaging studies, such as X-rays of the affected joints, and possibly ultrasound or MRI to assess for synovitis or erosive changes
- Fecal calprotectin testing to consider inflammatory bowel disease, given her GI symptoms
- Thyroid function tests, as thyroid disorders can present with joint pain and GI symptoms
A referral to rheumatology is warranted for further evaluation and management, as suggested by the 2017 EULAR recommendations 1. Addressing her obesity through weight management strategies may also help reduce joint pain and inflammation.
The 2022 ESMO clinical practice guideline for diagnosis, treatment, and follow-up of toxicities from immunotherapy also supports the use of a comprehensive rheumatologic workup, including joint count, ESR, CRP, RF, anti-CCP, and analysis of synovial fluid, as well as the consideration of systemic corticosteroids and csDMARDs for the management of inflammatory arthritis 1. However, the 2017 EULAR recommendations 1 provide more specific guidance for the management of early arthritis and are therefore prioritized in this recommendation.
From the Research
Further Workup Recommendations
The patient's symptoms and laboratory results suggest a possible diagnosis of rheumatoid arthritis (RA). Given the elevated CRP and ESR, normal ANA, and joint pain, further workup is recommended to confirm the diagnosis.
- The patient should undergo testing for anti-citrullinated protein antibodies (ACPAs) and rheumatoid factor (RF) to support the diagnosis of RA 2, 3, 4, 5.
- The presence of ACPAs is a sensitive and specific marker for RA, and the combined application of anti-CCP2 and anti-MCV assays can improve the laboratory diagnostics of RA 2.
- Additionally, testing for anti-carbamylated protein (anti-CarP) antibodies may provide further insight into the patient's condition, as recent studies suggest that ACPAs may arise from germline-encoded antibodies targeting carbamylated proteins 6.
- The patient's clinical presentation and laboratory results should be evaluated in the context of the latest research on autoantibodies in RA, including the role of RF, ACPAs, and other novel autoantibodies 5.
- A thorough evaluation of the patient's symptoms, medical history, and laboratory results is necessary to determine the best course of action for further workup and potential treatment.
- The presence of IgA isotypes of RF and ACPAs may provide prognostic information, and determination of these isotypes may be considered in the further workup of the patient 5.