A 56 year old gentleman was referred to our Rheumatology department in 2018 with pain, stiffness and swelling in his hands for several months. He reported pain and swelling in both metacarpophalangeal (MCP) joints and wrists. His past medical history included craniotomy and excision of right occipital arteriovenous malformation in 1989 with epilepsy secondary to this. He had a 20 pack-year smoking history and consumed 5 units of alcohol per week. He worked as a mechanic and did not have any family history of autoimmune conditions. The systems review was unremarkable.
On examination, he had active synovitis in bilateral second, third and fourth MCP joints with swelling of both his wrist joints. Initial blood results revealed raised inflammatory markers, negative Rheumatoid Factor (RF), strongly positive anti-cyclic citrullinated peptide antibody (ACPA) and negative anti-nuclear factor. Plain radiographs of his hands and feet showed mild osteopenia with no erosive changes.
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