Arthritis as an Initial Presentation of Malignancy

Two Case Reports

Benjamin Sachdev Manjit Singh; Sharifah Aishah Wan; Yaw Kiet Cheong; Seow Lin Chuah; Cheng Lay The; Ahmad Tirmizi Jobli


J Med Case Reports. 2021;15(94) 

In This Article

Case Presentation

Case 1

The patient was a 65-year-old woman of asian descent who was a former smoker for 20 years and had a history of spine surgery for L4/L5 degenerative disc disease. She was a retiree and a nondrinker. She presented with a 1-month history of oligoarthritis affecting both ankle joints associated with early morning stiffness of about 3 hours. On physical examination, the patient had swelling and tenderness of both ankle joints, with no other significant findings. She had no significant family history of malignancy or inflammatory arthritis. Laboratory tests were negative for rheumatoid factor (RF) but positive for antinuclear antibody (ANA) at a titer of 1:320 (speckled pattern). Erythrocyte sedimentation rate (ESR) was 61 mm/hour. Accordingly, she was treated for SpA, for which she was started on prednisolone 10 mg once daily and sulfasalazine (SSZ) 500 mg twice a day, without much improvement. Her SSZ was however withheld during a later clinic visit, as she developed macular rash after her dosage was increased to 1 g once daily. A routine chest radiograph (Figure 1) performed on her first visit incidentally revealed a right lung mass. Subsequent contrast-enhanced computed tomography (CT) of the thorax (Figure 2) showed a lung mass at the posterobasal segment of the right lower lobe measuring 4.7 × 7.0 × 7.0 cm (anteroposterior × width × craniocaudal). There were also satellite nodules adjacent to the mass. The mass was biopsied via bronchoscopy, and histopathological examination (HPE) results showed an adenocarcinoma favoring a primary lung malignancy, which showed a deletion in exon 19 of the epidermal growth factor receptor (EGFR) gene. Therefore, she was treated with tablet gefitinib 250 mg daily by the oncology team. The swelling of both ankles resolved with the initiation of gefitinib for her malignancy, with no recurrence on subsequent follow-up visits to the rheumatology clinic over the next 6 months. She was able to ambulate without any difficulty or pain. Her final diagnosis was revised to paraneoplastic arthritis secondary to adenocarcinoma of the lung. She was discharged to continue follow-up under the oncology team for her malignancy.

Figure 1.

Chest X-ray (posteroanterior erect view) with mass over the right lower lobe

Figure 2.

Sagittal computed tomography scan of the thorax demonstrates mass at the right lower lobe with associated surrounding satellite nodules (arrows)

Case 2

The patient was a 64-year-old woman of asian descent who was a nonsmoker, nondrinker and known to have hypertension, diabetes mellitus, dyslipidemia and ischemic heart disease. She was a retiree and was previously on the following medications: metformin 500 mg once daily, amlodipine 10 mg daily, atenolol 100 mg daily, isosorbide dinitrate 10 mg three times a day, aspirin 75 mg once a day, simvastatin 10 mg once daily and perindopril 2 mg daily. She presented with a 4-month history of asymmetrical polyarthritis involving her right wrist, second and third metacarpophalangeal joints (MCPJ), and first to fifth proximal interphalangeal joints (PIPJ) associated with loss of appetite and loss of weight. She however denied other constitutional symptoms. She had no family history of malignancy or connective tissue disease. Examination revealed swollen and tender joints involving her right wrist, second and third MCPJ and first to fifth PIPJ. There were no other significant physical findings on examination. Her routine laboratory workup was unremarkable aside from a raised ESR and positive antinuclear antibody at a titer of 1:160 (centromere pattern). Rheumatoid factor (RF) was negative, and a routine chest radiograph was unremarkable. X-rays of the hands showed arthritis changes in both hands, possibly RA. She was treated as seronegative RA and started on SSZ 500 mg twice daily and prednisolone 5 mg once daily, with poor clinical response. Six months after her initial arthritis, she presented to a private center with complaints of abdominal pain, resulting in a mini-laparotomy with omental biopsy. The omental HPE was reported as metastatic deposits of grade II serous cystadenocarcinoma of the ovary in the omentum. She was diagnosed with stage IIIc ovarian carcinoma and started neoadjuvant chemotherapy with intravenous administration of carboplatin AUC (area under the curve) 5 at day 1, with paclitaxel 80 mg/m2 on days 1, 8 and 15 for six cycles every 21 days. Her SSZ was withheld. After three cycles of chemotherapy, she developed new respiratory symptoms. A repeat CT of the thorax/abdomen revealed a left apico-posterior lung mass with multiple bilateral lung nodules, with an ill-defined hypodense mass at the region of the uterine fundus (Figures 3, 4). This was followed by a rigid bronchoscopy revealing a pedunculated tumor from the left upper lobe almost completely occluding the distal left main bronchus, which was biopsied. The biopsy showed a malignant tumor with sarcomatoid features. She proceeded to complete the six cycles of carboplatin/paclitaxel. A CT reassessment post-carboplatin/paclitaxel showed disease progression, as evidenced by a larger left lung mass on CT. She was then given second-line chemotherapy consisting of gemcitabine 1400 mg intravenously on day 1 and day 8, planned for three cycles and reassessment of response. Hence, her final diagnosis by the oncology team was dual malignancy (stage IIIc ovarian serous cystadenocarcinoma and malignant tumor with sarcomatoid features of the left lung). During all her follow-up visits with the oncology team she was noted to have no recurrence of her polyarthritis but was poorly responsive to her chemotherapy, with progressive respiratory symptoms. About 1 year after the initial diagnosis of polyarthritis, the patient succumbed to her illness after an admission for pneumonia.

Figure 3.

Coronal computed tomography scan image demonstrating uterine mass infiltrating the adjacent bowels and omentum (blue arrows)

Figure 4.

Sagittal computed tomography scan image demonstrating uterine fundus mass which has poor demarcation with the uterus inferiorly (arrow)