What is the likely diagnosis and initial management for a patient presenting with acute morning stiffness and pain in the finger joints accompanied by painful dry eyes?

Likely Diagnosis: Rheumatoid Arthritis with Secondary Sjögren's Features

The combination of sudden onset painful finger joints with morning stiffness and painful dry eyes strongly suggests rheumatoid arthritis (RA) with secondary sicca symptoms, requiring urgent rheumatology referral within 6 weeks and immediate initiation of disease-modifying therapy. 1, 2

Key Diagnostic Features Supporting RA

Morning stiffness duration is the critical differentiating feature:

• Stiffness lasting ≥60 minutes indicates inflammatory arthritis (likely RA), reflecting significant inflammatory processes during inactivity 1
• This contrasts with osteoarthritis, where stiffness is typically <30 minutes and mechanical in nature 1
• The stiffness should improve with movement and activity, which is pathognomonic for inflammatory conditions 1

Essential clinical examination findings to document:

• Look for soft tissue swelling (synovitis) around the finger joints—this is the cornerstone finding, not bony enlargement 2, 3
• Perform a "squeeze test": lateral compression of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints causing pain indicates synovitis and mandates urgent referral 1, 3
• Assess for symmetric involvement of small joints, particularly MCPs, proximal interphalangeal (PIP) joints, and wrists 2, 4
• Document whether distal interphalangeal (DIP) joints are spared—RA typically spares DIPs, while their involvement suggests osteoarthritis or psoriatic arthritis 2

Understanding the Dry Eye Component

The dry eye symptoms represent secondary sicca features, not primary Sjögren's syndrome:

• Approximately 15-30% of RA patients develop dry eye symptoms, particularly those with secondary Sjögren's syndrome 2
• The prominent inflammatory polyarthritis with acute onset and finger joint involvement is more consistent with RA as the primary diagnosis 2
• Primary Sjögren's syndrome would typically present with sicca symptoms as the dominant feature, not acute inflammatory polyarthritis 5

Initial dry eye management while addressing the underlying RA:

• Start preservative-free artificial tears containing methylcellulose or hyaluronate at least twice daily, increasing frequency up to hourly as needed 5
• Use ophthalmic ointments at bedtime for overnight symptom control 5
• Educate the patient that dry eye in RA is chronic and requires ongoing management 5

Immediate Diagnostic Workup (Do Not Delay Treatment)

Order these tests immediately, but do NOT wait for results before referring to rheumatology:

Autoimmune serology (cornerstone tests):

• Anti-CCP antibodies: High specificity (90%) for RA, moderate sensitivity (60%) 1, 2
• Rheumatoid factor (RF): Lower specificity (70%) but important for prognosis 1, 2
• Order both simultaneously—they are complementary, not redundant 2
• Critical pearl: Seronegative RA accounts for 20-30% of cases; negative RF does NOT exclude RA 2

Inflammatory markers:

• C-reactive protein (CRP): Preferred over ESR because it's more reliable and not age-dependent 1, 2
• ESR: Still obtain at baseline for diagnostic scoring and prognosis 1, 2
• Do NOT dismiss RA based on normal inflammatory markers—they can be normal even in active disease 2

Baseline safety labs (required before starting methotrexate):

• Complete blood count with differential to detect cytopenias 2
• Comprehensive metabolic panel including liver enzymes, renal function, glucose, and urate 2
• Urinalysis 2
• Hepatitis B, Hepatitis C, and tuberculosis screening (required before any biologic therapy) 2

Baseline imaging:

• Bilateral hand, wrist, and foot X-rays immediately 2
• Presence of erosions on baseline films is highly predictive of RA diagnosis and persistent disease 2
• If X-rays are negative but clinical suspicion is high, consider ultrasound with Power Doppler or MRI with contrast to detect subclinical synovitis 2, 3
• MRI-detected bone marrow edema is the strongest single predictor of future disease progression 2

Applying the 2010 ACR/EULAR Classification Criteria

A score of ≥6/10 points confirms definite RA: 2

Joint involvement (0-5 points):

• 1 large joint = 0 points
• 2-10 large joints = 1 point
• 1-3 small joints = 2 points
• 4-10 small joints = 3 points (likely applies here with finger involvement)

• 10 joints = 5 points

Serology (0-3 points):

• Negative RF and anti-CCP = 0 points
• Low-positive RF or anti-CCP = 2 points
• High-positive RF or anti-CCP = 3 points

Acute phase reactants (0-1 point):

• Normal CRP and ESR = 0 points
• Abnormal CRP or ESR = 1 point

Duration of symptoms (0-1 point):

• <6 weeks = 0 points
• ≥6 weeks = 1 point (if symptoms have been present this long)

Immediate Treatment Strategy (Start Before Rheumatology Appointment)

If clinical synovitis is present with morning stiffness ≥60 minutes, start treatment immediately:

First-line DMARD therapy:

• Methotrexate 15 mg weekly as the anchor drug 1, 2
• Plan to escalate to 20-25 mg weekly based on response 2
• Add folic acid 1 mg daily to reduce side effects 2
• Do NOT delay methotrexate waiting for positive serology—early treatment prevents irreversible joint damage 2

Bridge therapy while awaiting DMARD effect:

• Consider short-term low-dose prednisone (10-20 mg daily) for 2-4 weeks 5, 2
• This provides rapid symptom relief while methotrexate takes effect (typically 6-12 weeks) 2
• Taper and discontinue once DMARD effect is established 5

Treatment target:

• Aim for remission (SDAI ≤3.3) or low disease activity (SDAI ≤11) 2
• Reassess disease activity every 4-6 weeks using validated composite measures 2
• If inadequate response after 3 months of methotrexate, consider triple DMARD therapy or adding a biologic agent (TNF inhibitor) 2

Critical Pitfalls to Avoid

Do not delay referral or treatment based on:

• Normal inflammatory markers (ESR/CRP can be normal in active RA) 2
• Negative serology (20-30% of RA is seronegative) 2
• Absence of erosions on initial X-rays (erosions develop over time) 2

Do not confuse with:

• Osteoarthritis: Morning stiffness <30 minutes, bony enlargement (not soft tissue swelling), DIP joint involvement 1
• Psoriatic arthritis: Check for psoriatic plaques, nail pitting, dactylitis; typically anti-CCP negative 2
• Primary Sjögren's syndrome: Would require positive anti-SSA/anti-Ro antibodies (present in 40-60% of primary cases) and sicca symptoms as dominant feature 5, 2

Urgent Rheumatology Referral

Refer within 6 weeks of symptom onset if any of the following are present: 1, 3

• Morning stiffness ≥60 minutes PLUS visible/palpable joint swelling in ≥2 joints
• Positive squeeze test of MCPs or MTPs
• Symmetric small joint involvement

Why 6 weeks matters:

• Multiple studies demonstrate better long-term outcomes when treatment starts within this window 2
• Early aggressive treatment prevents irreversible joint damage and disability 1, 3
• The "window of opportunity" for preventing structural damage is narrow 3

Ophthalmology Referral for Dry Eye Management

Refer to ophthalmology if: 5

• Dry eye symptoms persist despite artificial tears
• Visual function is impaired (photophobia, decreased visual acuity)
• Severe ocular surface disease develops

The ophthalmologist should:

• Perform comprehensive ocular surface evaluation including tear film assessment 5
• Order serologic testing for Sjögren's syndrome if not already done: anti-SSA (anti-Ro), anti-SSB (anti-La), rheumatoid factor, and ANA 5
• Consider advanced imaging (meibography, tear film interferometry) if diagnosis is uncertain 5
• Escalate to topical cyclosporine 0.05% if first-line therapy fails 5