Radiographically Occult Manifestation of Rheumatoid Arthritis in a Patient With Prolonged Clinical and Laboratory Evidence of Rampant Disease: A Case Report.

OBJECTIVE: The purpose of this case report is to present a case of rampant rheumatoid synovitis and arthritis of a patient with a long duration of symptoms and no radiographic abnormalities of rheumatoid arthritis at the initial diagnosis. CLINICAL FEATURES: A 49-year-old Hispanic woman presented to a chiropractic teaching clinic with an 8-month history of bilateral, symmetrical hand pain and stiffness noted specifically in her second and third metacarpophalangeal joints. The patient has reported no other health changes and no history of rheumatoid arthritis in the family. INTERVENTION AND OUTCOME: Based on this patient's complaint, initial bilateral 3-view radiographic examination of the hands using computed radiography was performed. Despite prolonged history of inflammatory joint pain and rheumatoid arthritis confirmed by abnormally high levels of rheumatoid factor, C-reactive protein, and anti-cyclic citrulline peptide antibodies, the patient had no radiographic evidence of rheumatoid arthritis during the initial and repeat radiographic studies. CONCLUSION: Some patients with rheumatoid arthritis may present with rampant clinical and laboratory abnormalities despite an apparent lack of radiographically detectable rheumatoid arthritis. This case demonstrates that astute clinicians should primarily rely on the results of clinical and laboratory abnormalities of rheumatoid arthritis and not be deterred or mislead by an apparent lack of radiographic changes at diagnosis. If the diagnosis of rheumatoid arthritis requires diagnostic imaging confirmation, then magnetic resonance imaging or diagnostic ultrasound of the hands should be used, especially if the initial radiographic assessment remains unrewarding.

Radiographic Presentation of Delayed Diagnosis of Charcot Foot in a 56-Year-Old Patient With No Reported History of Diabetes: A Case Report.

OBJECTIVE: The purpose of this case report is to describe the radiographic presentation of a patient with neuropathic osteoarthropathy. CLINICAL FEATURES: A 56-year-old white man presented to the diagnostic imaging department of a chiropractic teaching institution for the radiographic examination of the left foot. He had a 6-month history of left foot pain unresponsive to chiropractic care. The patient had reported no history of diabetes and denied any trauma, surgery, or malignancy. INTERVENTION AND OUTCOME: Based upon the history, a 3-view radiographic examination of the left foot using computed radiography was performed. Radiographic abnormalities included osseous resorption, architectural foot disorganization, and dissociation and collapse of the anatomical alignment between the intertarsal and tarsal-metatarsal articulations. Intra-articular osseous debris formation with periarticular edema of the midfoot was noted. After the radiological diagnosis, the patient was subsequently investigated and diagnosed with type 2 diabetes mellitus. Thus, there were radiographic findings of poorly controlled or untreated diabetes mellitus with the resultant complication of neuropathic osteoarthropathy. CONCLUSION: Some patients with type 2 diabetes may present with covert manifestations and other symptoms, such as a history of unexplained foot pain. The patient in this case with diabetes-induced neuropathic osteoarthropathy demonstrates that these findings should raise suspicion and result in an appropriate follow-up investigation.