In January 2002 a 14 year old Turkish teenager presented to his doctor with a history of 3 months’ swelling of the proximal interphalangeal (PIP) joints of both hands. As arthritis was suspected, he was referred to an orthopaedic surgeon. Blood tests, including C reactive protein, rheumatoid factor, were normal, conventional radiography of both hands showed only soft tissue swellings of the PIP joints. Under the diagnosis of “juvenile rheumatoid arthritis”, treatment with a non-steroidal anti-inflammatory drug was started. As the “polyarthritis” persisted, he was introduced to another orthopaedist. Three phase bone scintigraphy (technetium-99m) disclosed intensive “hot spots” at the PIP joints (phase 2) and at the epiphysial growth plate of the upper and lower extremities (static bone phase).

In July 2003, after three other medical consultations, he was admitted to our department. He denied any other symptoms or complaints besides finger swellings (fig 1), predominantly of PIP 2 and 3 of both hands, …