Case report

A 73 year old English woman with seropositive, nodular, severe destructive rheumatoid arthritis (RA) and secondary Sjögren’s syndrome was seen with a 10 day history of pain and five day history of swelling in the left thigh.

She reported that she got out of bed 10 days ago, and felt pain in her left thigh, which she presumed to be a pulled muscle. She had difficulty in weight bearing and walking, but continued her already limited daily activities in a sheltered accommodation. Five days after this episode she noticed generalised swelling of her left thigh and developed fever (38.5°C), chills, headache, and malaise. The fever and associated symptoms resolved with high doses of acetaminophan, but the thigh pain and swelling progressively worsened to where she became bedridden. She had no history of swelling in her calves, recent surgery, prolonged immobilisation or any injury to her left thigh before the onset of pain.

Her past medical history was notable for debilitating RA of 30 years duration. Over the years, she had had bilateral hip arthroplasties and hand surgeries. She had developed a severe secondary Sjögren’s syndrome (diagnosis based on clinical criteria only) with corneal ulcerations despite regular use of artificial tears and protective glasses. She had lost all of her teeth except five; she wore dentures and used artificial saliva. Over the past eight years her RA was stable with prednisone 5 mg per day, methotrexate 7.5 mg orally per week, and nabumetone 500 mg twice a day. She was a widow and lived alone in a sheltered accommodation. She did not smoke. Her son and daughter in law who lived in the same town, helped her …