A 52-year-old white man presented with complaints of bilateral hand pain; he had a history of rheumatic fever, aortic valve replacement, corticosteroid-induced osteonecrosis, and total left hip arthroplasty.
The patient had been treated with oral corticosteroids and a biologic response modifier for several years for a diagnosis of rheumatoid arthritis (RA). Laboratory findings included negative antinuclear antibodies and rheumatoid factor (RF) test results and a normal erythrocyte sedimentation rate (ESR).
On examination, the patient was found to have ulnar deviation of both hands, along with mild subluxation at the metacarpophalangeal (MCP) joints, hyperextension of the proximal interphalangeal (PIP) joints, and flexion of the distal interphalangeal joints. There was no evidence of active synovitis in his hands or wrists.
X-ray films of both his hands were obtained and are seen here. A posteroanterior (PA) radiograph (top) of both hands firmly pressed against the plate shows hook erosions at the second and third MCP joints and mild periarticular osteopenia. Characteristic joint-space narrowing also is seen in the bilateral carpi. A PA radiograph (right) of both hands when lifted off the plate shows marked ulnar deviation that mimics RA and characteristic swan-necking of the first digit. In addition, an oblique x-ray view showed flexion deformities of the MCP joints.
What do the x-ray films show?
What is your diagnosis?
(Find the answer on the next page.)
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