Case Report


Synovial fluid interpretation and complex thinking as a key in management of unrecognized rheumatoid arthritis: A case report from family medicine practice

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1 Family Medicine Practice, Slavonski Brod, Croatia

2 Postgraduate Interdisciplinary University Study – Molecular Biosciences, University of Josip Juraj Strossmayer, Croatia

3 Department of Public Health, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

4 General Hospital Dr Josip Bencevic, Slavonski Brod, Croatia

5 Department of Internal Medicine, Family Medicine and the History of Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

Address correspondence to:

Zvonimir Bosnic

MD, PhD Student, Family Medicine Practice, Slavonski Brod, Croatia; Postgraduate Interdisciplinary University Study – Molecular Biosciences, University of Josip Juraj Strossmayer, Osijek, Croatia; Department of Public Health, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek,

Croatia

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Article ID: 100024Z14ZB2021

doi: 10.5348/100024Z14ZB2021CR

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How to cite this article

Bosnic Z, Ljiljak D, Bardak A, Kovacevic S, Sarie B, Majnaric LT. Synovial fluid interpretation and complex thinking as a key in management of unrecognized rheumatoid arthritis: A case report from family medicine practice. J Case Rep Images Orthop Rheum 2021;5:100024Z14ZB2021.

ABSTRACT


Introduction: Systemic inflammatory diseases, especially autoimmune diseases, such as rheumatoid arthritis (RA), are present difficulties in family medicine practice, due to atypical clinical presentation from patient to patient. In the background of the chronic polyarthritis, there is dysregulated immune response. Diagnostic approach and tools for RA involve several of following criteria, but there is some pathophysiological complexity, in those patients who present with atypical presentation. We report a case of synovial fluid interpretation and complex thinking as a key in management of unrecognized RA.

Case Report: Female patient, aged 50-years, presented to a family medicine with symptoms of polyarthritis. She was examined ambulatory (symmetrical pain in joints), lab tests were performed and were in normal range [complete blood count (CBC), differential blood count (DBC), erythrocyte sedimentation rate (SE), C-reactive protein (CRP), and low anti-CCP (<0.50 U/mL)]. Rheumatoid factor and Waaler–Rose test were both negative, urine test was pathological with the presence of leukocytes, serum protein electrophoresis revealed slightly higher albumin and Alfa 2 globulin, with low values of beta globulin and gamma globulin. Immunological blood tests were in normal range. Synovial fluid analysis showed high white blood cell (WBC) count, elevated IL-6, IL-8, and angiotensin-converting enzyme (ACE). Extensive diagnostics were performed. Foot X-ray revealed degenerative changes of the first metatarsophalangeal joint. The patient was treated with analgesic multiple drug combinations.

Conclusion: Pathophysiological complexity of understanding could be due to the agent triggering autoimmune disease, so it is possible that urinary tract infection (UTI) precipitated the onset of preexisting autoimmune disease, and synovial fluid interpretation confirmed diagnose. It is believed that therapy for rheumatoid arthritis (RA) is the most effective and beneficial within a short time frame around RA diagnosis.

Keywords: Autoimmune disease, Diagnostic approach, Immunological blood tests, Rheumatoid arthritis, Synovial fluid, UTI

SUPPORTING INFORMATION


Author Contributions

Zvonimir Bosnic - Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Daniela Ljiljak - Acquisition of data, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Ana Bardak - Acquisition of data, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Stjepan Kovacevic - Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Blazenka Saric - Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Ljiljana Trtica Majnaric - Substantial contributions to conception and design, Acquisition of data, Drafting the article, Final approval of the version to be published

Guarantor of Submission

The corresponding author is the guarantor of submission.

Source of Support

None

Consent Statement

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Conflict of Interest

Authors declare no conflict of interest.

Copyright

© 2021 Zvonimir Bosnic et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.