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 Case 5.1 Is this rheumatoid arthritis?

A 43-year-old woman presented to her GP with sudden onset of acute back pain while gardening, followed by more sustained but less severe pain over the next 2 weeks. The GP felt that this was mechanical back pain but perfomed some 'screening investigations' which included an erythrocyte sedimentation rate (ESR) of 4mm in the first hour (normal <10) and a positive test for rheumatoid factor at a titre of 1 in 256. She was then referred to her local rheumatology department with a possible diagnosis of rheumatoid arthritis. This caused the patient considerable anxiety as her aunt had had severe rheumatoid arthritis, leading to a very high level of disability. When she was seen in the rheumatology clinic 3 months later she still had minor back pain, but this was overshadowed by her anxiety. She had no other musculoskeletal symptoms and examination was normal apart from mild restriction of the lumbar spine. The rheumatologist agreed with the initial diagnosis of mechanical back pain and explained that around 5% of healthy normal people have a positive test for rheumatoid factor. Testing for rheumatoid factor is only useful in patients with a clinical picture consistent with rheumatoid arthritis where it is an important prognostic indicator.

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