Hand Pain and Swelling in a 63-Year-Old Woman

A 63-year-old woman presented to our rheumatology clinic with a 2-year history of bilateral hand pain and stiffness. The pain was most severe in the fingers and was associated with morning stiffness that lasted 30 minutes. The symptoms had worsened over the past few months, and there was loss of full range of motion in some finger joints.

The woman’s past medical history was unremarkable. She had experienced menopause about 15 years earlier. She reported that her mother had had similar problems with her hands. The patient
denied smoking and alcohol(Drug information on alcohol) use. She was an avid traveler and enjoyed hiking and scuba diving.

Physical examination showed prominent bony enlargements of multiple proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints bilaterally; some were tender to palpation. There was no synovitis, nail pitting, or onycholysis (see photo above). The patient could not make a complete closed fist.  

Laboratory test results showed an erythrocyte sedimentation rate (ESR) of 20 mm/h (normal range, 0 to 20 mm/h) and a C-reactive protein level of less than 0.4 mg/dL (normal range, 0 to 0.8 mg/dL). Rheumatoid factor (RF) was absent, and anticyclic citrullinated peptide (anti-CCP) antibody was 0 units (normal range, 0 to 20 units).

A complete blood cell count was obtained at another institution; the results were normal. An x-ray film of the hand showed joint-space narrowing in all the interphalangeal joints with erosions at the second through fifth PIP joints.

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