A 58-year-old male was referred to the rheumatology clinic for evaluation of arthralgia of the hands, wrists, and elbows. The patient's symptoms started six months prior and gradually worsened. The patient endorsed swelling of the hands and wrists, difficulty making fists, as well as morning stiffness lasting more than thirty minutes. He denied any constitutional symptoms such as fevers, chills, weight loss, decreased appetite, or night sweats. Review of systems was negative for alopecia, dry eyes, dry mouth, mouth sores, and skin rash. The patient also denied any recent travel, tick bites, or sick contacts. He never smoked and consumed alcohol on an occasional basis. The patient had a past medical history of osteoarthritis, with a surgical history significant for multiple procedures, including bilateral shoulder replacement for severe osteoarthritic changes, carpal tunnel repair of the right side, and laminectomy of the cervical and lumbar spine. Clinical exam revealed normal vitals, with benign head, eye, ear, nose, throat, cardiopulmonary, and abdominal exams. No lymphadenopathy or bruises were observed. Musculoskeletal exam revealed synovitis of the second through fifth metacarpophalangeal (MCP) and proximal interphalangeal regions bilaterally, with swelling and tenderness of the wrists with warmth to touch. In addition, there were 30-degree fixed contractions of the elbows. As per the patient, there was no history of psoriasis or nail changes, which was confirmed on physical exam as well. Laboratory data showed white blood cells of 12,000/mm, hemoglobin of 9.7 g/dl, hematocrit of 30.9%, C-reactive protein of 40 mg per liter (reference value <8), and erythrocyte sedimentation rate of 50 mm per hour (reference range 0 to 15). Laboratory testing of liver function, calcium, thyroid function, uric acid, renal function, and urinalysis was normal. Other normal or negative tests included antinuclear antibody, rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, hepatitis B panel, hepatitis C antibody, QuantiFERON-TB Gold test, and angiotensin-converting enzyme. The patient was seen by an outside rheumatologist and treated initially with prednisone 20 mg/d and methotrexate, which was quickly escalated to a dose of 20 mg/weekly, with no response after three months of treatment. He was subsequently started on antitumor necrosis factor inhibitors.
Six months later, a follow-up visit showed persistent symptoms. Alternative anti-TNF inhibitors were tried with no improvement. Further workup included X-rays of the hands and wrists, which showed mild degenerative changes only. Chest X-ray revealed no pathology. The patient underwent MRI of the right hand, which showed synovial thickening of the radiocarpal joint and MCP joints with flexor tendon tenosynovitis, compatible with inflammatory arthropathy (Figure 1). Further questioning of the patient revealed a family history of primary amyloidosis in his mother. Serum calcium, uric acid, and creatinine remained normal during the time of RA treatment. As a result, serum protein electrophoresis (SPEP) and urine protein electrophoresis were sent. Interestingly, SPEP was positive for M-band. The patient was then referred to hematology for further evaluation and underwent a bone marrow biopsy, which was positive for more than 40% plasma cells, as well as being Congo red stain negative, findings consistent with MM. FISH analysis was positive for monosomy 13 in 88% of the cells. The patient then started treatment for MM with bortezomib and dexamethasone. Six-month follow-up showed complete resolution of joint swelling, with significant improvement in pain of the hands, wrists, and elbows. His MM remained quiescent with chemotherapy, and the patient did not require bone marrow transplant.