J Rheum Dis.  2015 Oct;22(5):298-302. 10.4078/jrd.2015.22.5.298.

A Case of Rheumatoid Arthritis Presenting as an Intra-articular Mass of the Wrist Joint in a Patient with Chronic Monoarthritis

Affiliations
  • 1Division of Rheumatology, Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea. slera@yahoo.com
  • 2Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea.
  • 3Department of Pathology, Jeju National University School of Medicine, Jeju, Korea.
  • 4Department of Diagnostic Radiology, Jeju National University School of Medicine, Jeju, Korea.

Abstract

Rheumatoid arthritis (RA) mainly affects polyarticular joints and is characterized by inflammation of the synovial membrane leading to joint destruction. We report on an unusual case of RA presenting as an intra-articular mass invading bone of the wrist joint in a patient with chronic monoarthritis. A 43-year-old man presented with left wrist joint pain and swelling lasting several years. A plain radiograph showed a non-specific osteolytic lesion in the distal ulna but a magnetic resonance image demonstrated an intra-articular irregular mass-like lesion with eccentric bone erosion the distal radioulnar joint. Synovial biopsy detected hyperplasia of the synovial lining cell layer and finger-like protrusions of inflamed and edematous fibrovascular stroma containing dense inflammatory infiltrates, mainly plasma cells, B cells, and CD4+ T cells. Rheumatoid factor and anti-citrullinated protein antibody were highly positive. The patient was diagnosed with RA and treated with disease-modifying anti-rheumatic drugs, showing a good response on further follow-up.

Keyword

Rheumatoid arthritis; Intra-articular mass; Synovial biopsy

MeSH Terms

Adult
Antirheumatic Agents
Arthritis, Rheumatoid*
B-Lymphocytes
Biopsy
Follow-Up Studies
Humans
Hyperplasia
Inflammation
Joints
Plasma Cells
Rheumatoid Factor
Synovial Membrane
T-Lymphocytes
Ulna
Wrist Joint*
Wrist*
Antirheumatic Agents
Rheumatoid Factor

Figure

  • Figure 1. Abnormalties of the distal end and styloid process of the ulna. Radiolucent osteolytic lesion in ulnar head with sub-jacent resorption of bone on plain radiograph of the left wrist joint. Alterations on apposing surface of the distal ends of the radius and ulna.

  • Figure 2. Magnetic resonance imaging (MRI) abnormalities. (A) Coronal T1-weighted, (B) T1-weighted with enhancement, and (C) sagittal T2-weighted MRI of intra-articular irregular mas-like lesion of left distal ulna including extensive osseous involvement with enhancement. Eccentric bone erosion with suspicious overhanging edge at distal ulna and radioulnar joint. (D) Proton density-weighted image of bone marrow edema and marginal erosion with synovial hyperplasia at distal end of radio-unlar joint.

  • Figure 3. Histopathology of synovial tissue (H&E). (A) Marked synovial hyperplasia with formation of villi (×10) and (B) marked proliferation of synovial lining cells and dense inflammatory infiltrates (arrow), (C) predominantly plasma cells and lymphocytes with germinal center formation (arrow) (B, C: ×200).

  • Figure 4. Immunohistochemical (IHC) stain of (A) diffuse strong positivity for CD4 and (B) focal patchy positivity for CD8 (×200). Dense lymphocytic infiltrates mainly composed of CD4+ T cells.


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