Australian Doctor Australian Doctor 24th November 2017 | Page 14

Grand Rounds
The wrong drug?
THE AUTHOR
RHEUMATOLOGY
A long-term patient was seriously ill and needed hospital
care, but was her management evidence-based?
Dr David Bossingham, is
a retired rheumatologist
and associate professor
at James Cook
University College of
Medicine and Dentistry,
Queensland.
D
APHNE is a well-known 61-year-old
local councillor. The last time she saw
her GP was three years ago, when she
was diagnosed with rheumatoid arthri-
tis and was prescribed methotrexate.
The absence of follow-up visits and prescriptions
creates the impression that she has not been taking
the treatment.
Daphne presents complaining of breathlessness
on exertion, which has worsened over six weeks.
She has lost weight and feels tired. Daphne is an
ex-smoker who quit a decade ago and has had an
unproductive cough that has not changed for many
years.
Examination
Daphne has lost nearly 10kg since her last visit. She
has a low-grade fever of 37.5ºC, with otherwise
normal vital signs and no respiratory distress.
Her hair is thin and she has pale mucous mem-
branes. There is no cyanosis or clubbing. She has
a right pleural effusion and bilateral axillary lym-
phadenopathy. Her wrists and metocarpophalan-
geal joints are tender but are neither swollen nor
deformed.
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Investigation
Pathology reveals a normochromic normocytic
anaemia with haemoglobin 100g/L (normal
>120g/L).
Iron studies reveal a low serum transferrin and
ferritin. Biochemistry is unremarkable. CRP is
160mg/L (normal < 5mg/L).
Chest X-ray confirms a right pleural effusion.
Differential diagnoses include cancer, and infec-
tion. Her GP liaises with a local physician who rec-
ommends admission.
The hospital performs multiple further investiga-
tions. Mantoux is negative, as are syphilis, HIV,
hepatitis B and C serology, and tests for a host of
tropical infections. Daphne’s thyroid function is
also normal.
A pleural tap reveals a very high white cell count
with low glucose, high LDH and cytosine deami-
nase.
None of these findings differentiate infection
from malignancy. However, pleural fluid cytology
is negative. Bronchoscopy is negative.
An axillary lymph node biopsy is performed,
which reveals reactive changes only.
The haematological team is asked to review
Daphne.
They request immunoglobulin analysis, which
reveals a small monoclonal peak in the IgA sub
fraction enabling a diagnosis of a monoclonal gam-
mopathy of uncertain significance (MGUS), which
is unlikely to be the cause of her presenting com-
plaints.
A bone marrow biopsy is performed and the
result is unremarkable. The haematology opinion
is that the anaemia is due to chronic disease.
Daphne has a persistent low-grade fever, without
any evidence of either significant malignancy or
infection, so a rheumatology opinion is requested.
Further history assessment reveals that Daphne
took methotrexate for two months only and
CLINICAL AUDIT
stopped taking the drug when her symptoms eased.
She now has a swollen joint count of six and a
tender joint count of 20, but no joint deformity.
Progress
Systemic rheumatoid arthritis is considered the
most likely diagnosis based on Daphne’s recent
symptoms and clinical findings.
She wa