Winning Abstracts from the 2011 Medical Student Abstract Competition: Rheum for Debate
Author: Rebekah Condit, Texas A&M College of Medicine, Class of 2012
Introduction:Feltyís Syndrome (FS) is classically defined as a triad of rheumatoid arthritis, splenomegaly, and neutropenia, and is found in 1-3% of patients with rheumatoid arthritis. First described in 1924 there are new definitions and concurrent debate over therapy. There are no randomized control trials on treatment of Feltyís syndrome; current goals of treatment focus on increasing the neutrophil count, preventing infections, addressing the splenomegaly, and/or treatment of rheumatoid arthritis.
Case Presentation: A 50-year-old Caucasian male presents with a 2.5 day history of redness and increased swelling of his right little finger. The symptoms began with a splinter, and the next day he had erythema up to his right axilla, pain, fever, chills, and clear fluid drainage. The patient has no other significant history. The patient denied history of STDs, HIV, and IVDA (IV drug abuse), but endorsed a 70-pack-year history of tobacco abuse. On admission, the patient was afebrile with a palpable spleen and erythema and ecchymosis of right little finger. The patientís WBC count was 0.9 on two separate occasions, and absolute neutrophil count was 108. His CRP and ESR were 117 and 29 respectively. The patientís workup revealed a positive ANA, Rheumatoid factor, and anti-citrulline antibody along with clinical and radiographic signs of rheumatoid arthritis. Splenomegaly measuring 19 cm was confirmed on ultrasound. The triad of rheumatoid arthritis, splenomegaly and neutropenia was consistent with Feltyís Syndrome. The patient was discharged on antibiotics, a colony-stimulating factor for his neutropenia, and had follow-up appointments with Rheumatology and Hematology clinics.
Discussion: Recent research suggests there is a new definition for Feltyís syndrome; unexplained neutropenia with rheumatoid arthritis. The evolution of the disease has created a debate about the classification and treatment of Feltyís Syndrome. Research has shown that Feltyís syndrome may be included in a spectrum of disease with T-cell large granular lymphocyte leukemia, TLGL, with an umbrella of Rheumatoid arthritis. FS and TLGL are clinically and biologically similar with no specific test for differentiating the two diseases. This spectrum of disease leads to a question of whether treatment of FS and TLGL should be early and aggressive treatment of rheumatoid arthritis or treatment of neutropenia, infection, and splenomegaly.
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