Tubercular tenosynovitis is an uncommon condition and usually affects the upper limb. We report a case of a patient with Systemic Lupus Erythematosus who presented with wrist swelling. The clinical findings were suggestive of rheumatoid nodules, but the radiographic finding of calcification associated with the nodules and marked erosive changes primarily of the radio-carpal joint with sparing of the metacarpal joints led the radiologist to believe that the nodules may not be rheumatoid nodules. The presence of solid and fluid nature of the nodule and hyperechoic small echogenic foci (matted rice bodies within thickened synovium) on ultrasound suggested the presence of chronic synovitis of tuberculous infection rather than rheumatoid nodule as in our case. We recommend the use of ultrasound to determine the nature of nodular swellings seen clinically in patients with arthropathy.
1. Revised ARA criteria (1987) the diagnosis of RA requires presence of at least 4 of the following 7 features: 1) morning stiffness> 1 hour 2) swelling of 2 or more joints (of 6 weeks duration) 3) symmetrical joint involvement 4) arthritis of more than 1 hand joints (of at least 6 weeks duration) 5) positive rheumatoid factor, 6) presence of rheumatoid nodule 7) X-ray changes. 2. Use of DMARD should start early, along with pain control by non steroidal anti inflammatory drugs (NSAID) 3. Early referral to rheumatologists is the current recommendation 4. Indications for early referral include: i. Early morning stiffness (EMS) of 30 mins ;- ii. Metatarsophalangeal (MTP) / metacarpophalageal (Mep) involvement. iii. 2 or more swollen joints.
In West Malaysia RA appears to be less common than in temperate climates, but more common than in tropical Africa; furthermore, the incidence of gout and SLE is comparable. The clinical manifestations of RA are milder than those seen in more temperate climates. Subcutaneous rheumatoid nodules have not been observed. Positive serological tests for RF are significantly higher than in the general Malaysian population, but still lower than those reported for patients with RA in temperate climates. Of the three main ethnic groups, the highest incidence of positive results is found in the Chinese.
Study site: Arthritis Clinic, University Hospital, Kuala Lumpur (University Malaya Medical Centre, UMMC, Kuala Lumpur, Malaysia)