A 54-year-old male presented to our department with arthritis, involving multiple joints. His symptoms started in 2007. When he first developed spontaneous arthritis of third proximal interphalangeal (PIP) joint, presented with painful swelling, accompanied by morning stiffness lasting for hours and relieved by warmth and activity. In July 2012, the above-mentioned symptoms were aggravated. Multiple arthralgia and swollen joints involved in bilateral PIP joints, wrists, elbows, knees, and ankles joints, along with a limited range of motion. He visited our hospital and was diagnosed as RA. The symptoms were relieved after starting on treatment with corticosteroids, NSAIDs (loxoprofen, celecoxib), and immunosuppressive agents (methotrexate, leflunomide). Having outpatient review and treatment regularly in our hospital, his condition was stable. At the beginning of 2015, he suffered from nontender subcutaneous nodules on the left forearm. The nodule could disappear with injection of corticosteroids. The symptoms appeared repeatedly but he paid no attention to it. Since then, he followed up with his rheumatologist intermittently. He is currently on medication with prednisone (5 mg/d), NSAID, and methotrexate (15 mg /w). During the course of disease, there was no xerostomia, xerophthalmia, rampant tooth, recurrent oral or genital ulcers, hair loss, photosensitivity, rashes, Raynaud's phenomenon, lower back pain, or talalgia. Particularly, proteinuria was present. He did not have any nocturia, oliguria, pollakisuria, urgent urination, odynuria, or gross hematuria. Defecation was normal. His body weight did not change obviously.
In mid-November 2015, the patient presented to our department of rheumatology with the complaints of the swelling and pain of multiple joints and edema of bilateral lower limbs. There were no symptoms in the respiratory, cardiovascular, and gastrointestinal systems. On examination, nontender subcutaneous nodules measuring 2 x 1.5 cm (rheumatoid nodule confirmed) over the extensor surface on the left forearm with no limitation of range of motion. Tenderness and swelling of the second and third PIP joints of right hand, the third PIP joints of left hand, bilateral knees, wrists, shoulders, and ankles were present. Pitting edema was present in the lower limbs, and bilateral palpebral edema was also present. The laboratory examination showed as follows: erythrocyte sedimentation rate 88.00 mm/h, C-reactive protein 18.8 mg/L, purified protein derivative test, tuberculosis antibody or T-cell spot test were negative, 24 hours urine protein 12.56 g/24 h, albumin 18.30 g/L (normal>40 g/L), serum total cholesterol 12 mmol/L (normal<5.7 mmol/L), triglyceride 2.37 mmol/L (normal<1.7 mmol/L), creatinine 82 mummol/L, rheumatoid factor 1280 Iu/mL, antiperinuclear factor 1:80, antikeratin antibody 1:80, anticyclic cirullinated peptide antibodies 826.2 RU/mL, human leucocyte elastase +, anti-SSA, anti-SSB, anti-SM, anti-RNP, anti-Jo1, anti-Scl70, anti-double-stranded deoxyribonucleic acid, cytoplasmic antineutrophil cytoplasmic antibody (ANCA), perinuclear ANCA, protease-3, myeloperoxidase, anti-mitochondrial antibody, and human leukocyte antigen-B27 were normal or negative.
Renal biopsy revealed glomeruli with segmental sclerosing lesions. The electrolyte microscope showed no electron-dense deposits and only visceral epithelial cell foot process effacement (Fig. 1). To stop the progressing of disease, we used methyprednisolone160 mg/4 days, human albumin 20 mg/5 days, prednisone acetate15 mg /QD, celecoxib200 mg/BID, leflunomide10 mg/QD, and other symptomatic treatment. After intensive treatment proteinuria level dropped to 7.2 g/24 h, serum albumin levels were increased to 24.9 g/L, renal function gradually returned to normal, and the patient was discharged in a stable condition.
This case report has been approved by the Ethics Committee of the Second Hospital of Shanxi Medical University and got the written consent of the patient.