An 80-year-old man was diagnosed with wrist and knee pain 2 years ago and was treated by a family care physician. Before 1 year, computed tomography (CT) revealed multiple pulmonary nodules, and the patient underwent transbronchial lung biopsy (TBLB), which showed no evidence of tuberculosis, fungus, bacterial infection, vasculitis or malignancy. After 1 year, he was referred to our department following new onset of fever and finger joint pain.
He had symmetric polyarthritis with active synovitis affecting both the metacarpophalangeal and proximal interphalangeal joints (> 12 joints). Laboratory findings were negative for RF and anti-CCP antibodies, but serum C-reactive protein levels were elevated. The patient fulfilled the classification criteria of the 2010 American College of Rheumatology/European League Against Rheumatism and was diagnosed with seronegative RA. We performed TBLB for pulmonary nodules again; however, it did not reveal any findings suggesting malignancy and infection. The pulmonary nodules diminished after the treatment with prednisolone (PSL) 15 mg/day and methotrexate 12 mg/week for seronegative RA (Fig. 1). Therefore, we speculated that these were rheumatoid nodules.
The patient complained of pain in both eyes associated with redness 2 months post-treatment. The patient had conjunctival injection (Fig. 2), and optical coherence tomography showed retinal edema and diffuse thickening of the choroid (Fig. 3). Furthermore, extravascular leakage was observed by fundus fluorescein angiography (Fig. 4). Consequently, the patient was diagnosed with RA-associated scleritis complicated by uveitis and retinal vasculitis. Steroid eye drops were prescribed and the oral PSL dose was increased to 40 mg; however, the retinal edema worsened. We administered sub-Tenon's triamcinolone acetonide (STTA) injection, which gradually improved his scleritis. Thereafter, the PSL dosage was tapered without relapse.