Not All Rheumatoid Factor-Positive Tests Mean RA

Pathak et al. reported a case of AITL in association with Guillain-Barré syndrome diagnosed after rapid onset of ascending lower extremity paralysis.¹² In this case the patient developed lymphadenopathy after being discharged, and immunohistological biopsy later revealed the diagnosis.¹²

The correlation of malignancy with rheumatic illness is a complex, fascinating aspect of immunology. The arthritis associated with AITL can present very similarly to that of RA, with symmetric involvement of proximal joints. It is usually non-erosive, sero­negative and non-deforming, but is typically associated with constitutional symptoms and elevated markers of inflammation.

Although [the G17V mutation of Ras homolog family member A] mutation has also been identified in other malignancies, … it may serve as a non-invasive diagnostic test for AITL in the future.

The arthritis of AITL responds well to low to moderate prednisone doses, but remains unresponsive to disease-modifying anti-rheumatic drugs and biologic response modifiers. Our patient demonstrated this with multiple relapses after his prednisone dose was decreased.

This case highlights several diagnostic and therapeutic challenges. First, not all positive rheumatoid factor tests are associated with RA.

Second, a patient’s difficulty tolerating a taper in prednisone, especially when used in conjunction with other disease-modifying drugs or biologic response modifiers, should prompt the rheumatologist to consider an alternative etiology for arthritis.

Finally, failure of RA to respond to triple or even quadruple therapy should also prompt concern for an alternative etiology.

Francis Essien, DO, is an internal medicine resident at Keesler Medical Center, Keesler Air Force Base, Miss.

Matthew B. Carroll, MD, FACP, FACR, is a rheumatologist with Singing River Health System, Ocean Springs, Miss.

References

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