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Oligoarthritis in an elderly woman with diarrhoea and weight loss

An 80 year old woman was referred in 1995 to the haematology outpatient department with a normocytic anaemia and weight loss. She was found to be deficient in iron, folic acid, and vitamin B12 and was started on replacement treatment. A barium meal and enema were normal and antiparietal cell antibodies negative. In 1997 she fell, fracturing her right proximal ulna and distal humerus. In April 1999 she developed intermittent diarrhoea and lost further weight. There was no rectal bleeding. A sigmoidoscopy, rectal biopsy, and computed tomography pneumocolon were all normal. In September she was referred to the rheumatology outpatient department with a three month history of painful swollen ankles, chest pains, and generalised weakness. Her bowel habit had returned to normal. She continued on folic acid 5 mg/day, hydroxycobalamin 1 mg/month, and ferrous sulphate 375 mg/day, and was taking diclofenac 25 mg twice a day for her pain.

On examination she was cachectic. She was not clinically anaemic and there was no lymphadenopathy. There was a 2 cm tender liver edge but the remainder of the abdominal examination was normal. Both ankles were swollen and tender (fig 1). There was a fixed flexion deformity and the right elbow and mild weakness of the proximal musculature. There was tenderness of the chest wall, but no muscle tenderness.



Figure 1 
Bilateral ankle swelling and proximal muscle wasting.



Initial investigations showed a haemoglobin of 124 g/l, mean corpuscular volume 92 fl, white cell count 10.4 × 109/l, and platelets 558 × 109/l. The erythrocyte sedimentation rate was 30 mm/hour and C reactive protein 1 mg/l. The red cell folate was low at 92 μg/l (normal range 150–700) with a normal vitamin B12 of 254 ng/l (160–800). Iron studies were normal, as were the serum …