A 24 yo F with no PMH with 6 months of joint pain and puffy hands. Mother with systemic lupus erythematosus. ROS notable for Raynaud’s (view image) and mild dyspnea on exertion.
Physical Exam
- Synovitis of MCPs and wrists
- Pitting at distal fingertips (view image); nailfold capillaroscopy
- Normal pulmonary exam; RRR, prominent S2
Diagnostic Workup
- Labs:
- Hemoglobin 10.6, MCV 82; remaining CBC and BMP WNL
- High titer ANA, speckled pattern; high titer RNP; Negative Smith, Ro, La, dsDNA, centromere, Scl 70, RF, CCP antibodies
- Imaging:
- CXR: Normal lung fields
- TTE: Dilated RV with normal function; normal LV size and function
Treatment & Further Workup
- Hydroxychloroquine for inflammatory arthritis
- Calcium channel blocker for Raynaud’s
- Right heart catheterization for workup of pulmonary artery hypertension
A 29 yo F presents to the ED for acute-onset, electric shock pain over the L side of the face. Diagnosed with trigeminal neuralgia. ROS also notable for trouble going up and down stairs and dyspnea on exertion.
Physical Exam
- Mildly puffy/swollen hands; no synovitis
- Severe tenderness to palpation of L face
- 4-/5 strength of BL iliopsoas and deltoids; otherwise normal neurologic exam
- Normal cardiopulmonary exam
- No rashes
Diagnostic Workup
- Labs:
- High titer ANA, speckled pattern; high titer RNP; Negative Smith, Ro, La, dsDNA, centromere, Scl 70, RF, CCP antibodies, myositis panel
- CK 1,037
- Imaging:
- CXR shows reticular opacities at the BL bases (view image); CT demonstrates NSIP pattern of ILD (view image); TTE normal
- MRI thigh with diffuse muscle edema (view image)
Treatment
- Prednisone 40mg daily
- Carbamazepine for trigeminal neuralgia
- Mycophenolate mofetil for ILD and myositis
