Another Onset Mode for Rheumatoid Arthritis : Emergency Lab , Ultrasound or Both ? Case Report and Literature Review

1 ”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Internal Medicine Emergency, “Sf. Ioan” Clinical Hospital, Bucharest, Romania 3 Department of Pediatric-Hematology, Fundeni Clinical Hospital, Bucharest, Romania 4 EUREKA CT/MRI Department, “Sf. Ioan” Emergency Clinical Hospital, Bucharest, Romania 5 Department of Internal Medicine, Emergency Clinical Hospital, Bucharest, Romania Corresponding author: Alice Balaceanu, Department of Internal Medicine, “Sf. Ioan” Clinical Emergency Hospital, 13th Vitan-Barzesti Avenue, 42122, Bucharest, Romania. E-mail: alicebalaceanu@yahoo.com Abstract


INTRODUCTION
Rheumatoid arthritis is a systemic autoimmune disease, with complex etiology and multiple genetic, immunologic, hormonal factors 1 .Th e onset could be insidious, like in the most patients or acute, with synovitis and extra-articular manifestations, encountered in 10% of patients 1 .

MATERIALS AND METHODS
We report a case of a 41 years old woman, non-smoker, without medical history, who complains about intermittent leg pain for 2 months, initially left calf, than bilateral, with edema in the both ankle and calf.Th e patient denied trauma.She is referred to emergency department for deep vein thrombosis suspicion.Cli-nical exam showed important edema of both legs.Lab tests: microcytic hypochromic anemia (Hb 7.8 g/dL, HCT 26.6 %), mild leukocytosis with elevated neutrophils (WBC 12.0 x10 9 /L, Gran 76.9 %), secondary thrombocytosis (PLT 694x10 9 /L), infl ammatory biological syndrome (ESR 83 mm/h, Fibrinogen 684 m/ dL, CRP 160.21 mg/L), low serum iron levels (24 μg/ dL).Doppler ultrasound of lower limbs showed deep veins without thrombosis; complex fl uid collection in the calves that begins above the popliteal space (Figure 1), more than 100 mm long diameter, inhomogeneous, hypoechoic.
Clinical presentation of disseminated intravascular coagulation was chronic, bleeding type.Underlying con ditions like sepsis or severe infection, trauma, malignancy, severe hepatic lesions, vascular lesions, toxic or immunologic reactions were evaluated.
Blood tests for B and C hepatitis and screening anti-HIV antibodies were negative.

RESULTS AND DISCUSSION
Disseminated intravascular coagulation (DIC) has four variants: hyperfi brinolysis with bleeding, hypercoagulation, consumptive type with severe, fatal bleeding and non-symptomatic type 3 .Th e underlying etiological conditions make the diff erences between the clinical manifestations, but the types could change or shift 3,4 .D-dimer and fi brinogen degradation products (FDP) elevations are specifi c parameters for bleeding type of DIC 3 , while high plasma levels of factor VIII and VWF, characteristic fi ndings in DIC, cause platelet-vessel wall interaction, with organ failure 5 .Th e hypercoagulant status of infl ammatory rheumatic di-sease implies endothelial activation, disturbance of plasmatic factors, dyscrasia, platelet activation, hyperviscosity 5 .In rheumatoid arthritis cases elevated CRP, ESR, fi brinogen, factor VIII and VWF increase plasma viscosity 6 .Endothelial cells play an important role in infl ammatory rheumatic disease, DIC as presenting symptom at onset being also reported 7 .High values of CRP and ESR, anemia of chronic disease and thrombocytosis are characteristic features of rheumatoid vasculitis 8,9,10 .
Activated platelets play also an important role in the infl ammatory response of the synovial vessels: they promote vascular permeability, releasing infl ammatory cytokines with an active role in leukocyte-mediated tissue infl ammation 11,12 .
In an ultrasonographic study, the most frequently causes of Baker's cyst were osteoarthritis and rheumatoid arthritis 13 .Associated hematoma to Baker's cyst is an uncommon complication 14 .Ruptured Baker cyst could mimic deep vein thrombosis 15,16 .
In our case the presenting symptom was painful bilateral calf edema caused by hemorrhagic giant Baker's cysts.Th e diagnostic was made by Doppler ultrasonography and confi rmed by contrast-enhanced CT and MRI.Acute onset of rheumatoid arthritis with severe infl ammation of synovial knee joints and giant hemorrhagic cysts made the diagnosis very diffi cult, in the context of disseminated intravascular coagulation manifestations.As in other complex diseases, the diagnosis approach must be synergistic 17 .Th e evolution under appropriate treatment scheme and systematic surveillance was favorable.

CONCLUSIONS
Rheumatoid arthritis is a complex autoimmune condition, with a challenging diagnosis due to its multiple faces and its capricious coagulation and hematological implications.
Confl ict of interests: none declared.Financial support: none declared.Th e patient has given the informed written consent.

Figure 3 .
Figure 3. Contrast-enhanced MRI of the left calf (sagittal vue): Baker's cysts containing scratchy material, probably bleeding; moderate amount of fluid in the joint knees, changes of reactive synovitis.

Figure 1 .
Figure 1.Doppler ultrasound of the calf: complex fluid collection, inhomogeneous, hypoechoic, no Doppler color signal, 25 mm short diameter, more than 100 mm long diameter, probably organized hematoma.

Figure 2 .
Figure 2. CT of the legs (axial vue): fluid encapsulated collections, well organized, with thin walls, heterogeneous serum and hemorrhagic densities, suggesting possible hematoma in bilateral gastrocnemius muscles.