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ISSN: 2161-1149
Rheumatology: Current Research

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Forearm Mass in Rheumatoid Arthritis: Infection or Malignancy

Norah A. Musallam1, Shehanah F. AlOmair1 and Mohammed A. Omair2*

1College of Medicine, King Saud University, Riyadh, Saudi Arabia

2Rheumatology Department, Collage of Medicine, King Saud University, Riyadh, Saudi Arabia

*Corresponding Author:
Mohammed A. Omair
College of Medicine
King Saud University
Riyadh, Saudi Arabia
Tel: 966505270513
E-mail: [email protected]

Received date: August 01, 2016; Accepted date: August 02, 2016 Published date: August 05, 2016

Citation: Musallam NA, AlOmair FS, Omair MA, (2016) Forearm Mass in Rheumatoid Arthritis: Infection or Malignancy. Rheumatology (Sunnyvale) 6:203. doi:10.4172/2161-1149.1000203

Copyright: © 2016 Musallam NA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

Rheumatoid arthritis; Tuberculosis; Infection; Methotrexate; Immunosuppression

Case Presentation

A 60-year old Saudi Caucasian female with a 10-year history of Rheumatoid Arthritis and Diabetes Mellitus, treated with prednisolone 5 mg daily, MTX 15 mg weekly and etanercept 50 mg weekly, presented with a swelling in the volar aspect of the right forearm just below the cubitus fossa for 2 months duration. The swelling was preceded by generalized pain in the whole right upper limb that limited her movement for one week. There was no history of recent trauma, respiratory symptoms, fever, weight loss, night sweats or loss of appetite. Patient denied any history of prior tuberculosis (TB) or a close contact with a TB patient. PPD prior to initiation of Etanercept was negative. Clinical examination showed a solitary, skin colored, stony, hard, non-tender non-pulsatile, fixed nodule with irregular borders measuring about 7 × 10 cm. The overlying skin had no signs of redness, dilated veins, sinus or scars. MRI of the right elbow illustrated multinucleated collection involving the subcutaneous area with insinuation between muscle fibers with a possible connection to the joint space. Erosive changes within the elbow were present with no signs of osteomyelitis.

Ultrasound guided true cut biopsy was performed and histopathological examination showed necrotizing granulomatous inflammation with positive Ziehl–Neelsen stain for acid fast bacilli, consistent with mycobacterial infection with no evidence of coexisting malignant cells.

CT chest-abdomen-pelvis revealed multiple pulmonary and hilar nodules; the largest measuring 1.5 × 2.4 cm. CT abdomen: Liver was mildly enlarged with a homogenous enhancement with no focal lesion.

Etanercept was discontinued, patient was started a 4 drug regimen: isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months then kept on isoniazid and rifampin for a total duration of 9 months. After 3 months of treatment, the mass regressed significantly. At 6 months, Etanercept was resumed with almost complete resolution of the mass and good tolerability to therapy.

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Conflict of Interest

The authors have no conflict of interest.

Financial Disclosure

The authors declare no financial interest, and the case report was not funded by any external funding agency.

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