By Dr Irwin Lim, Rheumatologist
My grandmother lives overseas.
A couple of months ago, she developed pain and swelling in the joints. She gets the best care money can buy in the country she lives in so she did the medical rounds, and also explored, because her family are inclined that way, the complementary or "alternative" health options.
I received some emails and WhatsApp updates, and had to dabble in this case with advice from afar. This is always fraught with problems but as you will understand, it's not something I can say no to.
She was given NSAIDs to try and help the suffering. I worry about this a little given she's close to 90 years-old with a not-so-healthy heart, and old kidneys. I think she was given cortisone at some stage and this will of course help.
In the end, she did get to see a rheumatologist. Whew!
The rheumatologist diagnosed seronegative inflammatory arthritis and commenced her on Methotrexate at low dose, 10mg weekly.
There is some irony in this given I write about Methotrexate a lot to try and allay some misguided fears about this medication. Some of her family have read my blog and were reasonably comfortable with the medication.
As I am. Unless the diagnosis is not correct. Because, the drug is less likely to work in other conditions which can mimic autoimmune-based seronegative inflammatory arthritis.
Last week, the hand swelled diffusely and from the pictures sent to me, her elbow also appeared swollen. She would have been in a lot of pain.
The diagnosis needed to be reconsidered. In an elderly female, with the diffuse swelling at her hand/wrist, I usually worry about crystal arthritis, gout or pseudogout.
She was admitted to hospital for investigations and the diagnosis was changed to Pseudogout based on some changes seen on an Xray (I assume this was chondrocalcinosis), and an aspirate of joint fluid which did not show any infection (infection is unlikely given the multiple joints involved).
Methotrexate has been stopped and her medications rejigged.
Being in the game, I can definitely vouch that diagnosing the cause of inflammatory arthritis can often be difficult. Blood tests can often be unhelpful. Preliminary investigations may not provide any definitive features.
Many times, experience and judgement allow a best guess. And, all of us rheumatologists will get in incorrect some times. Being open to a rethink is important. Having a good enough rapport with the patient so that they trust/respect/like you enough to return when things are not going well is important.
We're hoping the diagnosis is clearer this time.....but it may not be.
Sometimes, the passage of time and repeat review is the only way to clarify things.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.