Patient Case: Rheumatoid Arthritis in a Sub-Saharan African Setting
A 42-year-old female presents to a rural clinic with a six-month history of progressive joint pain, swelling, and morning stiffness lasting over an hour. She reports that the symptoms began in her fingers and wrists and have since spread to her knees and ankles. The pain is persistent and worsens with activity. She also complains of generalized fatigue, intermittent low-grade fever, and unintentional weight loss over the past few months.
Medical History & Social Background
The patient has no known history of prior joint diseases or trauma. She has four children and works as a farmer, frequently using her hands for daily tasks. There is no known family history of autoimmune diseases. Due to limited access to healthcare, she initially relied on herbal remedies and over-the-counter painkillers before seeking medical attention.
Physical Examination
• Symmetrical swelling and tenderness in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of both hands, as well as in both knees.
• Ulnar deviation and early signs of joint deformity in the fingers.
• Warmth over affected joints with moderate effusion.
• No skin rashes, nodules, or signs of infection.
• Limited grip strength and difficulty in making a fist.
Laboratory & Imaging Findings
• Rheumatoid factor (RF): Positive
• Anti-cyclic citrullinated peptide (anti-CCP) antibodies: Positive
• Erythrocyte sedimentation rate (ESR): Elevated
• C-reactive protein (CRP): Elevated
• X-ray of the hands: Shows periarticular osteopenia and early joint space narrowing.
• Full blood count: Mild anemia of chronic disease, normal white blood cell count.
Diagnosis
Based on the clinical presentation, serology, and imaging, the patient is diagnosed with rheumatoid arthritis (RA), seropositive, moderate activity.
Management Plan
1. Pharmacologic Treatment.
• Methotrexate 10 mg weekly with folic acid supplementation.
• Non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief.
• Prednisolone (low-dose, short-term) for flare management.
• Patient education on the importance of adherence to disease-modifying anti-rheumatic drugs (DMARDs).
2. Non-Pharmacologic Treatment
• Referral to a physiotherapist for joint protection strategies and mobility exercises.
• Dietary counseling to ensure adequate nutrition and manage weight.
• Guidance on assistive devices to reduce joint strain during daily activities.
3. Follow-Up & Monitoring
• Monthly follow-ups to assess treatment response and side effects.
• Monitoring of liver function and blood counts due to methotrexate use.
• Adjustments in therapy based on disease progression and patient response.
Challenges & Considerations
• Limited access to rheumatologists and specialized care.
• Financial constraints affecting long-term medication adherence.
• High dependency on traditional medicine, requiring community-based awareness programs on RA.
Prognosis
With early diagnosis and initiation of treatment, the patient has a good chance of slowing disease progression and maintaining functional independence. However, regular follow-up and lifestyle modifications will be essential in managing the condition and preventing disability.
A) Osteoarthritis
B) Rheumatoid arthritis
C) Gout
D) Systemic lupus erythematosus
A) Elevated erythrocyte sedimentation rate (ESR)
B) Positive rheumatoid factor (RF)
C) Positive anti-cyclic citrullinated peptide (anti-CCP) antibodies
D) Mild anemia of chronic disease
A) Hydroxychloroquine
B) Methotrexate
C) Prednisolone
D) Non-steroidal anti-inflammatory drugs (NSAIDs)
A) Availability of NSAIDs
B) High cost and accessibility of DMARDs
C) Overuse of antibiotics
D) Limited need for follow-up care
