Artritis

CASO CLÍNICO

FROM

A

NEUTROPHILIC TO A R H E U M AT O I D

SYNOVIAL

TISSUE OF

I N F I LT R AT E

CHALLENGING ARTHRITIS

CASE

Ana Filipa Mourão*, Helena Canhão*,**, Elsa Sousa*,**, Rita Cascão*, João Borges da Costa***, Luís Soares de Almeida***, Maria Emília Oliveira****, Manuel Marques Gomes***, Mário Viana Queiroz**, João Eurico Fonseca*,**

Abstract
The herein reportillustrates how a synovial tissue heavily infiltrated by neutrophils in the first weeks of arthritis, can evolve in few months to a synovial infiltration by lymphocytes with a characteristic pattern of rheumatoid arthritis (RA). This observation suggests a critical initial role of neutrophils in RA onset, which is eventually surpassed by the activation of the adaptive immune system. In addition,this patient, despite the absence of rheumatoid factors and anti-cyclic citrullinated peptide antibodies, progressed to a highly destructive and disabling disease, that was only controlled adequately with rituximab, due to the lack of response to methotrexate and serious adverse effects with TNF blockers therapy. Keywords: Early Rheumatoid Arthritis; Synovitis; Neutrophils; Adverse Drug Reaction;Anti-Tumour Necrosis Factor Agents.

vial tissue heavily infiltrated by neutrophils can occur during RA onset, being latter on converted into the classic synovial pattern of this disease. Despite the absence of rheumatoid factor (RF) and anticyclic citrullinated peptide antibodies (anti-CCP), the clinical evolution of this patient was poor. The difficulties in the clinical management wereincreased by the lack of response to methotrexate and to the occurrence of severe adverse events with TNF antagonists. These drawbacks led to the introduction of rituximab therapy with an adequate clinical response.

Case report
A 33 year-old woman presented with an acute asymmetric oligoarthritis initiated in the previous week, involving the left ankle, right knee and wrist with associatedtenosynovitis. She also referred morning stiffness lasting 30 minutes and on clinical observation no skin lesions or fever could be detected. Her past and family history were irrelevant. Laboratorial evaluation showed normal blood count, elevated erythrocyte sedimentation rate (38 mm/1st hour) and C reactive protein (2.5 mg/ /dL). Serum RF, anti-CCP antibody, antinuclear antibodies were not detectable andHLA B27 was also negative. Serological tests to Human Immunodeficiency Virus, Borrelia burgdorferi, Cytomegalovirus, Epstein-Barr virus, B and C hepatitis virus were negative as well as urinary sediment and bacteriological exam of vaginal swab. Hands and wrists, ankles and knees, feet, chest and sacroiliac radiographs were normal. Synovial biopsy of the right knee revealed the presence of an acuteinflammatory infiltrate with predominance of polymorphonuclear cells, suggesting an infectious process (Figure 1a). Despite of a negative synovial fluid culture she was treated with ceftriaxone (1 g im/day), du-

Introduction
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterized by synovial hyperplasia caused by a large cellular leukocyte infiltrate and highexpression of proinflammatory cytokines, leading to erosions and increased remodelling of joint cartilage and bone. The herein case report demonstrates how the presence of a syno*Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina de Lisboa, Lisbon **Rheumatology Department of Centro Hospitalar de Lisboa Norte, Hospital de Santa Maria, EPE, Lisbon ***Dermatology Departmentof Centro Hospitalar de Lisboa Norte, Hospital de Santa Maria, EPE, Lisbon ****Pathology Department of Centro Hospitalar de Lisboa Norte, Hospital de Santa Maria, EPE, Lisbon

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