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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

This month: A noteworthy case study

What to do for a 106-year-old woman who suddenly lost her mobility over the course of a few months, after being able to walk unassisted and live independently in her own home? That's what Ahmed Dheyaa Al-Obaidi, MBChB, of the University of Baghdad in Iraq, and colleagues had to figure out, as they recounted in .

The patient noted that she had recently consulted a general practitioner but had been misdiagnosed with osteomalacia, after which she had been started on a regimen of vitamin D and calcium supplements.

She told clinicians that she had a relative who had been diagnosed with rheumatoid arthritis (RA) that had been treated with methotrexate and rituximab for 5 years.

Physical examination found her vital signs to be within normal ranges. Clinicians noted that she had significant inflammation and tenderness in her hands and feet, which presented as bilateral swelling in her wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints. The metatarsophalangeal joints of both feet were similarly swollen and painful, to the extent that she had been unable to stand on her feet for the previous 3 months.

She did not smoke, and had long-standing, although well-controlled, hypertension of 20+ years.

Clinicians considered several differential diagnoses, including inflammatory arthritis, crystal arthritis, and degenerative arthritis, and also wondered if her symptoms were related to dysfunction of the endocrine system or perhaps reflected cancer-related musculoskeletal symptoms.

Lab tests showed that her hemoglobin was 10 g/dL, erythrocyte sedimentation rate (ESR) was 65 mm/h, and C-reactive protein and rheumatoid factor were both positive. Serum uric acid, liver function, renal function, and thyroid function were all within normal ranges, and screening tests for viral infections were negative.

Chest x-ray and abdominal ultrasound findings were both unremarkable, and x-rays of the hands revealed bilateral osteopenia and erosion at the wrists, and MCP and PIP joints. Hand deformities included ulnar deviation, Z-shaped deformity of both thumbs and wrists, and swelling of the MCP joints.

Imaging and blood tests confirmed the diagnosis of rheumatoid arthritis, and the patient was started on methotrexate 7.5 mg weekly and folic acid 5.0 mg weekly. To help address the side effects of nonsteroidal anti-inflammatory drugs, clinicians also prescribed paracetamol for pain.

When the patient returned for follow-up, she reported that her pain levels had gradually diminished so that she was able to walk again without help, and her appetite had improved.

Follow-up testing showed that her ESR value had decreased to 40 mm/h and there was no change in liver function. She continued with treatment, and was scheduled for regular follow-up assessments.

Discussion

Al-Obaidi and co-authors called the case "extremely rare" and said that by reporting the case, believed to be the first in the literature in a patient of this age, they hoped "to encourage medical professionals to concentrate on diagnosing old patients with unusual presentation of rheumatoid arthritis."

RA is a chronic, progressive multisystemic inflammatory disease by damaging synovitis, which ultimately destroys the joints, resulting in loss of function and disability. The condition is associated with decreased quality of life and increased morbidity and mortality. RA can affect any joint, but "is most often associated with erosive alterations in the tiny joints of the hand and foot," the case authors explained.

Although the incidence of RA is considered to peak from ages 30-50, recent data suggest an increasing number of cases (approximately 2%) that develop in people in their late 60s -- so-called (EORA), the team noted.

Several clinical characteristics have been identified that distinguish EORA from young (earlier)-onset RA. Al-Obaidi and colleagues cited a suggesting that EORA has a "more equal gender distribution, a higher frequency of acute onset with constitutional symptoms," and that patients are less likely to be positive for rheumatoid factor (RF) or anti-cyclic citrullinated peptide antibody.

EORA has three different clinical presentations, Al-Obaidi and colleagues said. The first type, which accounts for about 70% of EORA cases, is more likely to be RF-positive and involve joint erosions; this type has a comparatively worse prognosis than young-onset rheumatoid arthritis.

"The second variant (25%) is a polymyalgia rheumatica (PMR)-like form with involvement of the proximal limb joints," the authors noted. This type tends to be negative for RF, to develop more rapidly, generally does not involve joint erosions, and has a more favorable prognosis. "Asymmetric nonerosive polyarthritis may develop in 25% of PMR patients; hence, a differential diagnosis is important to be excluded," the team wrote.

The third type of EORA is similar to remitting seronegative symmetrical synovitis with pitting edema in terms of both its clinical pattern and prognosis, the case authors noted, explaining that the literature is conflicting as to whether the outcomes of EORA patients are better or worse compared with those with earlier-onset RA.

This lack of a predictable prognosis makes it challenging to advise patients. However, recent data to help guide treatment decisions, including from a 2022 suggested that the time to remission is similar in the two RA groups.

Those researchers speculated that because of the older age of EORA patients, they are more likely to be fragile, to have co-existing comorbidities, and to have a greater risk of disease-modifying antirheumatic drug (DMARD) related .

Given the case report patient's age of 106, treatment decisions were complicated by the presence of comorbidities, even though her condition showed significant improvement using DMARDs, Al-Obaidi and co-authors added.

Read previous installments of this series:

Part 1: RA Beginnings: Before the Painful Joints

Part 2: RA: Still a Clinical Diagnosis

Part 3: RA: Choosing Initial Treatment