A case of carpal tunnel syndrome in patient with rheumatoid arthritis

Abstract

Background. Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy caused by compression of the median nerve at the wrist, and most likely the most common peripheral neurological involvement in patients with rheumatoid arthritis. It is manifested withpain and/either paresthisias at night associated with weakness, loss of dexterity and even thenar atrophy. Case report. We report a case of a female patient GN, 42y.o., with established seropositive (FR-153 IU/L; anti-CCP – 340 U/ml), highly active (DAS28-5.47) Rheumatoid Arthritis. Now she presented with inflammatory joint pain and swelling in 11 joints (including elbow bilaterally, wrist bilaterally, metacarpophalangeal, and proximal interphalangeal joints), morning stiffness is more than2 hours, additionally she reports numbness, tingling and burning in the 1,2 and 3rd fingers of the left hand. Carpal tunnel syndrome was suspected. Both Tinel’s (paresthesia in a median nerve distribution, after percussion of the median nerve at the wrist) and Phalen’s (paresthesia in a median nerve distribution, after passive flexion of the hand at the wrist) signs were positive. The patient recalls having similar symptoms in the right hand 3 years ago. An EMG exam performed at that time was showing: Prolongation of the median motor distal latency and median F-wave abnormalities. A diagnosis of carpal tunnel syndrome was established the patient being treated with surgical approach by neurolysis of the median nerve. Considering thatthe patient presented with swelling in the left wrist joint, it was decided to do an infiltration of corticosteroids. The patient had a satisfactory recovery with resolution of all carpal tunnel symptoms within 1 week. When looking for a detailed history of disease itwas concluded that the carpal tunnel syndrome in the right hand occurred most likely also as a consequence of joint swelling which is frequently disregarded as an important and easily treatable cause of carpal tunnel syndrome. However, the situation was less clear due to the fact that it occurred at the onset of rheumatoid arthritis. Conclusions. Carpal tunnel syndrome is the most frequent nerve entrapment condition associated with RA. Although diagnosis is at time tricky, one shouldn’t prompt surgical approach since most cases are caused by flexor tenosynovitis which responds well to injections with corticosteroids. However to prevent development of such complication, effective disease modifying therapy should be in place.