Clinical Images: Rheumatologic irony


The patient, a 57-year-old man, first presented with mild arthralgia in the metacarpophalangeal (MCP) joints. Radiographs obtained at that time (A) clearly showed degenerative changes in the MCP joints, with hook-like osteophytes (arrows). Laboratory evaluation revealed an elevated ferritin level as well as transferrin saturation, and genetic analysis confirmed hereditary hemochromatosis (C282Y homozygous). The patient subsequently underwent regular phlebotomy, but reported worsening of joint pain with new-onset symmetric synovitis. Three years later, he presented to our outpatient clinic with recent radiographs (B), which revealed complete resorption of the osteophytes seen 3 years earlier, and additional bone erosions in the MCP and carpal joints (arrowheads). Magnetic resonance imaging of the right hand showed massive synovitis, and seronegative rheumatoid arthritis was diagnosed. Coincident occurrence of hereditary hemochromatosis and rheumatoid arthritis has been described. However, to our knowledge, this is the first documented case in which the 2 diseases sequentially involved the same joints, with a complete transition from a proliferative phenotype with osteophyte formation to an erosive disease with complete resorption of the osteophytes that had previously grown over a long period of time.1

Illustration 1.