{"version":"1.0.0","segments":[{"startTime":1.875,"endTime":3.2,"body":"[intro music]"},{"startTime":3.2,"endTime":5.6,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.2,"endTime":5.6,"body":"to Harrison's Podclass,"},{"startTime":5.6,"endTime":8.72,"body":"where we discuss important"},{"startTime":5.6,"endTime":8.72,"body":"concepts in internal medicine."},{"startTime":8.72,"endTime":9.86,"body":"I'm Cathy Handy."},{"startTime":9.86,"endTime":11.743,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.86,"endTime":11.743,"body":"Wiener and we're coming to you"},{"startTime":11.743,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.83,"endTime":17.873,"body":"Okay, welcome to episode 58,"},{"startTime":17.873,"endTime":20.17,"body":"a 65-year-old with joint pain."},{"startTime":20.17,"endTime":21.836,"body":"- Hi Cathy."},{"startTime":20.17,"endTime":21.836,"body":"- [Dr. Handy] Hey Charlie."},{"startTime":21.836,"endTime":23.14,"body":"[Dr. Wiener] Okay, well today's case"},{"startTime":23.14,"endTime":24.87,"body":"is a 65-year-old woman"},{"startTime":24.87,"endTime":28.05,"body":"with a 10-year history of"},{"startTime":24.87,"endTime":28.05,"body":"untreated rheumatoid arthritis"},{"startTime":28.05,"endTime":30.38,"body":"who presents to your clinic"},{"startTime":28.05,"endTime":30.38,"body":"with worsening joint pain"},{"startTime":30.38,"endTime":32.69,"body":"and malaise over the last six months."},{"startTime":32.69,"endTime":34.01,"body":"On examination of her joints,"},{"startTime":34.01,"endTime":37.4,"body":"she has swan neck deformities"},{"startTime":34.01,"endTime":37.4,"body":"in all her deviations."},{"startTime":37.4,"endTime":38.233,"body":"Let's stop there"},{"startTime":38.233,"endTime":40.41,"body":"and talk a little bit"},{"startTime":38.233,"endTime":40.41,"body":"about rheumatoid arthritis."},{"startTime":40.41,"endTime":42.24,"body":"[Dr. Handy] Okay, so in"},{"startTime":40.41,"endTime":42.24,"body":"rheumatoid arthritis,"},{"startTime":42.24,"endTime":44.73,"body":"the most common joints"},{"startTime":42.24,"endTime":44.73,"body":"that you would see involved"},{"startTime":44.73,"endTime":47.76,"body":"would be the wrist, the"},{"startTime":44.73,"endTime":47.76,"body":"metacarpophalangeal joints,"},{"startTime":47.76,"endTime":50.51,"body":"and the proximal interphalangeal joints."},{"startTime":50.51,"endTime":52.6,"body":"Distal interphalangeal joint involvement"},{"startTime":52.6,"endTime":54.59,"body":"is rarely due to rheumatoid arthritis"},{"startTime":54.59,"endTime":58.14,"body":"and more often due to"},{"startTime":54.59,"endTime":58.14,"body":"coexisting osteoarthritis."},{"startTime":58.14,"endTime":60.86,"body":"Swan neck deformity, like"},{"startTime":58.14,"endTime":60.86,"body":"you mentioned in this case,"},{"startTime":60.86,"endTime":63.85,"body":"refers to the hyperextension"},{"startTime":60.86,"endTime":63.85,"body":"of the PIP joint"},{"startTime":63.85,"endTime":66.05,"body":"with flexion of the DIP joint,"},{"startTime":66.05,"endTime":69.02,"body":"which is most commonly seen"},{"startTime":66.05,"endTime":69.02,"body":"in rheumatoid arthritis."},{"startTime":69.02,"endTime":70.74,"body":"[Dr. Wiener] As part of"},{"startTime":69.02,"endTime":70.74,"body":"the initial evaluation,"},{"startTime":70.74,"endTime":72.62,"body":"oftentimes we obtain plain radiographs"},{"startTime":72.62,"endTime":74.67,"body":"in patients with suspected RA."},{"startTime":74.67,"endTime":76.95,"body":"Plain radiographs are readily available"},{"startTime":76.95,"endTime":79.75,"body":"and they allow easy film comparison."},{"startTime":79.75,"endTime":81.38,"body":"What would you expect radiographically"},{"startTime":81.38,"endTime":83.63,"body":"early and late in the presentation of RA?"},{"startTime":83.63,"endTime":85.87,"body":"Note, this woman supposedly"},{"startTime":83.63,"endTime":85.87,"body":"has not had treatment"},{"startTime":85.87,"endTime":87.07,"body":"for 10 years."},{"startTime":87.07,"endTime":89.457,"body":"[Dr. Handy] The earliest"},{"startTime":87.07,"endTime":89.457,"body":"radiologic sign of RA"},{"startTime":89.457,"endTime":91.89,"body":"is juxta-articular osteopenia,"},{"startTime":91.89,"endTime":93.97,"body":"although this may be"},{"startTime":91.89,"endTime":93.97,"body":"difficult to appreciate"},{"startTime":93.97,"endTime":96.33,"body":"on some of the newer digitized films."},{"startTime":96.33,"endTime":97.57,"body":"Other findings that you would see"},{"startTime":97.57,"endTime":101.05,"body":"include soft tissue swelling,"},{"startTime":97.57,"endTime":101.05,"body":"symmetric joint space loss,"},{"startTime":101.05,"endTime":104.24,"body":"and subchondral erosions"},{"startTime":101.05,"endTime":104.24,"body":"most frequently in the wrist,"},{"startTime":104.24,"endTime":105.539,"body":"the metacarpophalangeal"},{"startTime":105.539,"endTime":107.63,"body":"and the proximal interphalangeal joints"},{"startTime":107.63,"endTime":110.12,"body":"and metatarsophalangeal joints."},{"startTime":110.12,"endTime":111.89,"body":"[Dr. Wiener] Okay, so"},{"startTime":110.12,"endTime":111.89,"body":"radiology is still useful"},{"startTime":111.89,"endTime":113.438,"body":"in this diagnosis it sounds like."},{"startTime":113.438,"endTime":114.36,"body":"[Dr. Handy] Mmhmm."},{"startTime":114.36,"endTime":116.43,"body":"[Dr. Wiener] Okay, well let's"},{"startTime":114.36,"endTime":116.43,"body":"get back to this patient."},{"startTime":116.43,"endTime":119.23,"body":"Her skin examination"},{"startTime":116.43,"endTime":119.23,"body":"demonstrates rheumatoid nodules"},{"startTime":119.23,"endTime":121.52,"body":"in the olecranon bursa bilaterally,"},{"startTime":121.52,"endTime":123.73,"body":"and notably on abdominal examination,"},{"startTime":123.73,"endTime":125.17,"body":"you palpate her spleen,"},{"startTime":125.17,"endTime":127.3,"body":"she clearly has splenomegaly."},{"startTime":127.3,"endTime":128.43,"body":"[Dr. Handy] Splenomegaly in someone"},{"startTime":128.43,"endTime":131.1,"body":"with nodular rheumatoid"},{"startTime":128.43,"endTime":131.1,"body":"arthritis, like you mentioned,"},{"startTime":131.1,"endTime":133.57,"body":"should make you think of Felty's syndrome."},{"startTime":133.57,"endTime":134.82,"body":"[Dr. Wiener] Well, I'll"},{"startTime":133.57,"endTime":134.82,"body":"give you some lab studies."},{"startTime":134.82,"endTime":135.653,"body":"How about that?"},{"startTime":135.653,"endTime":136.71,"body":"[Dr. Handy] That would be helpful."},{"startTime":136.71,"endTime":139.16,"body":"[Dr. Wiener] Well, her laboratory"},{"startTime":136.71,"endTime":139.16,"body":"studies show neutropenia,"},{"startTime":139.16,"endTime":142.37,"body":"an elevated C-reactive protein and anemia."},{"startTime":142.37,"endTime":145.42,"body":"And as you predicted, she's"},{"startTime":142.37,"endTime":145.42,"body":"diagnosed with Felty's syndrome."},{"startTime":145.42,"endTime":146.97,"body":"So tell me more about that."},{"startTime":146.97,"endTime":149.3,"body":"[Dr. Handy] Felty's syndrome"},{"startTime":146.97,"endTime":149.3,"body":"is a clinical diagnosis"},{"startTime":149.3,"endTime":152.59,"body":"and it's defined by the"},{"startTime":149.3,"endTime":152.59,"body":"clinical triad of neutropenia,"},{"startTime":152.59,"endTime":154.11,"body":"which you mentioned on her labs,"},{"startTime":154.11,"endTime":156.92,"body":"splenomegaly, which we"},{"startTime":154.11,"endTime":156.92,"body":"noted on physical exam,"},{"startTime":156.92,"endTime":159.17,"body":"and nodular rheumatoid arthritis."},{"startTime":159.17,"endTime":161.44,"body":"It's seen in less than"},{"startTime":159.17,"endTime":161.44,"body":"1% of patients, though,"},{"startTime":161.44,"endTime":162.67,"body":"so it's quite rare,"},{"startTime":162.67,"endTime":165.18,"body":"and its incidence appears"},{"startTime":162.67,"endTime":165.18,"body":"to be declining in the face"},{"startTime":165.18,"endTime":167.84,"body":"of more aggressive treatment"},{"startTime":165.18,"endTime":167.84,"body":"of the joint disease,"},{"startTime":167.84,"endTime":169.18,"body":"as it typically occurs really"},{"startTime":169.18,"endTime":171.87,"body":"in late stages of severe"},{"startTime":169.18,"endTime":171.87,"body":"rheumatoid arthritis."},{"startTime":171.87,"endTime":173.01,"body":"[Dr. Wiener] So it sounds like this lady"},{"startTime":173.01,"endTime":174.324,"body":"is a setup for that."},{"startTime":174.324,"endTime":175.932,"body":"[Dr. Handy] Right, exactly."},{"startTime":175.932,"endTime":177.89,"body":"[Dr. Wiener] So the"},{"startTime":175.932,"endTime":177.89,"body":"question is going to ask us,"},{"startTime":177.89,"endTime":180.22,"body":"what type of hematologic malignancy"},{"startTime":180.22,"endTime":183.04,"body":"or lymphoproliferative"},{"startTime":180.22,"endTime":183.04,"body":"disorder may present"},{"startTime":183.04,"endTime":184.95,"body":"similarly to Felty's syndrome"},{"startTime":184.95,"endTime":187.31,"body":"in patients with rheumatoid arthritis?"},{"startTime":187.31,"endTime":191.61,"body":"And the options are A."},{"startTime":187.31,"endTime":191.61,"body":"acute myeloid leukemia;"},{"startTime":191.61,"endTime":194.43,"body":"B. chronic lymphocytic leukemia;"},{"startTime":194.43,"endTime":197.48,"body":"C. essential thrombocytosis;"},{"startTime":197.48,"endTime":200.055,"body":"D. polycythemia vera;"},{"startTime":200.055,"endTime":205.038,"body":"or option E. a T-cell large"},{"startTime":200.055,"endTime":205.038,"body":"granular lymphocyte leukemia."},{"startTime":205.038,"endTime":206.57,"body":"[Dr. Handy] Of the diseases listed,"},{"startTime":206.57,"endTime":209.5,"body":"T-cell large granular lymphocyte leukemia,"},{"startTime":209.5,"endTime":212.64,"body":"or T-LGL for short because"},{"startTime":209.5,"endTime":212.64,"body":"that's also easier to say,"},{"startTime":212.64,"endTime":214.55,"body":"may have a similar clinical presentation"},{"startTime":214.55,"endTime":217.545,"body":"and it often occurs in"},{"startTime":214.55,"endTime":217.545,"body":"association with RA."},{"startTime":217.545,"endTime":220.62,"body":"[Dr. Wiener] Wow. Tell me about T-LGL."},{"startTime":220.62,"endTime":222.55,"body":"[Dr. Handy] So it's"},{"startTime":220.62,"endTime":222.55,"body":"characterized by a chronic"},{"startTime":222.55,"endTime":225.21,"body":"indolent clonal growth of LGL cells,"},{"startTime":225.21,"endTime":228.09,"body":"and that leads to"},{"startTime":225.21,"endTime":228.09,"body":"neutropenia and splenomegaly."},{"startTime":228.09,"endTime":231.748,"body":"As opposed to Felty's syndrome,"},{"startTime":228.09,"endTime":231.748,"body":"T-LGL may develop early"},{"startTime":231.748,"endTime":234.1,"body":"in the course of rheumatoid arthritis."},{"startTime":234.1,"endTime":237.16,"body":"Leukopenia apart from"},{"startTime":234.1,"endTime":237.16,"body":"these disorders is uncommon"},{"startTime":237.16,"endTime":240.93,"body":"and occurs more commonly as a"},{"startTime":237.16,"endTime":240.93,"body":"side effect of drug therapy."},{"startTime":240.93,"endTime":243.095,"body":"[Dr. Wiener] Okay. So what"},{"startTime":240.93,"endTime":243.095,"body":"about the other answers then?"},{"startTime":243.095,"endTime":244.61,"body":"[Dr. Handy] Splenomegaly can be seen"},{"startTime":244.61,"endTime":246.21,"body":"in any of the malignancies listed,"},{"startTime":246.21,"endTime":250.27,"body":"although probably less common"},{"startTime":246.21,"endTime":250.27,"body":"in AML compared to the others."},{"startTime":250.27,"endTime":251.93,"body":"Neutropenia is not as common"},{"startTime":251.93,"endTime":255.45,"body":"in essential thrombocytosis"},{"startTime":251.93,"endTime":255.45,"body":"and polycythemia vera."},{"startTime":255.45,"endTime":258.81,"body":"Additionally, AML, CLL,"},{"startTime":255.45,"endTime":258.81,"body":"essential thrombocytosis,"},{"startTime":258.81,"endTime":261.19,"body":"and polycythemia vera are not seen"},{"startTime":261.19,"endTime":263.07,"body":"more frequently in patients with RA"},{"startTime":263.07,"endTime":265.34,"body":"compared to the general population."},{"startTime":265.34,"endTime":266.71,"body":"[Dr. Wiener] What about lymphoma though?"},{"startTime":266.71,"endTime":268.89,"body":"[Dr. Handy] Lymphoma is"},{"startTime":266.71,"endTime":268.89,"body":"increased in patients with RA,"},{"startTime":268.89,"endTime":271.47,"body":"but is not typically"},{"startTime":268.89,"endTime":271.47,"body":"similar to Felty's syndrome"},{"startTime":271.47,"endTime":273.79,"body":"in terms of its clinical presentation."},{"startTime":273.79,"endTime":275.77,"body":"The most common type of lymphoma diagnosed"},{"startTime":275.77,"endTime":279.11,"body":"in patients with RA is"},{"startTime":275.77,"endTime":279.11,"body":"diffuse large B-cell lymphoma."},{"startTime":279.11,"endTime":280.99,"body":"[Dr. Wiener] Okay. You"},{"startTime":279.11,"endTime":280.99,"body":"mentioned that Felty's syndrome"},{"startTime":280.99,"endTime":283.02,"body":"is pretty rare, so let's get back"},{"startTime":283.02,"endTime":286.41,"body":"to a more general question"},{"startTime":283.02,"endTime":286.41,"body":"about rheumatoid arthritis."},{"startTime":286.41,"endTime":287.54,"body":"The question asks,"},{"startTime":287.54,"endTime":290.06,"body":"patients with rheumatoid"},{"startTime":287.54,"endTime":290.06,"body":"arthritis are at higher risk"},{"startTime":290.06,"endTime":291.83,"body":"for all of the following health conditions"},{"startTime":291.83,"endTime":294.46,"body":"than the general population, except?"},{"startTime":294.46,"endTime":298.1,"body":"So options are A. colorectal cancer;"},{"startTime":298.1,"endTime":300.008,"body":"B. coronary artery disease;"},{"startTime":300.008,"endTime":303.02,"body":"C. hypoandrogenism;"},{"startTime":303.02,"endTime":304.849,"body":"D. lymphoma;"},{"startTime":304.849,"endTime":306.946,"body":"and E. osteoporosis."},{"startTime":306.946,"endTime":308.21,"body":"[Dr. Handy] The most common cause of death"},{"startTime":308.21,"endTime":311.32,"body":"in patients with RA is"},{"startTime":308.21,"endTime":311.32,"body":"cardiovascular disease."},{"startTime":311.32,"endTime":313.37,"body":"The incidence of coronary artery disease"},{"startTime":313.37,"endTime":316.92,"body":"and carotid atherosclerosis"},{"startTime":313.37,"endTime":316.92,"body":"is higher in RA patients"},{"startTime":316.92,"endTime":318.67,"body":"than in the general population,"},{"startTime":318.67,"endTime":321.56,"body":"even when you control for"},{"startTime":318.67,"endTime":321.56,"body":"traditional cardiac risk factors"},{"startTime":321.56,"endTime":324.15,"body":"like hypertension,"},{"startTime":321.56,"endTime":324.15,"body":"obesity, high cholesterol,"},{"startTime":324.15,"endTime":326.35,"body":"diabetes and cigarette smoking."},{"startTime":326.35,"endTime":327.3,"body":"[Dr. Wiener] And you already mentioned"},{"startTime":327.3,"endTime":330.28,"body":"that the risk of lymphoma"},{"startTime":327.3,"endTime":330.28,"body":"is increased in RA patients."},{"startTime":330.28,"endTime":331.71,"body":"[Dr. Handy] Yeah, large cohort studies"},{"startTime":331.71,"endTime":334.73,"body":"have shown a two to four-fold"},{"startTime":331.71,"endTime":334.73,"body":"increased risk of lymphoma"},{"startTime":334.73,"endTime":337.71,"body":"in RA patients compared"},{"startTime":334.73,"endTime":337.71,"body":"with the general population."},{"startTime":337.71,"endTime":338.69,"body":"And like I mentioned before,"},{"startTime":338.69,"endTime":341.63,"body":"the most common histopathologic"},{"startTime":338.69,"endTime":341.63,"body":"sight that you would get is"},{"startTime":341.63,"endTime":343.81,"body":"a diffuse large B-cell lymphoma."},{"startTime":343.81,"endTime":345.5,"body":"[Dr. Wiener] What about"},{"startTime":343.81,"endTime":345.5,"body":"the other answers then?"},{"startTime":345.5,"endTime":347.21,"body":"[Dr. Handy] Well, with regards to cancer,"},{"startTime":347.21,"endTime":349.43,"body":"which as you know is my favorite topic,"},{"startTime":349.43,"endTime":351.84,"body":"RA has not been associated"},{"startTime":349.43,"endTime":351.84,"body":"with increased rates"},{"startTime":351.84,"endTime":354.3,"body":"of colorectal cancer or other solid tumors"},{"startTime":354.3,"endTime":355.81,"body":"with the exception of lung cancer,"},{"startTime":355.81,"endTime":357.54,"body":"which is slightly increased."},{"startTime":357.54,"endTime":360.039,"body":"[Dr. Wiener] Okay. So the answer"},{"startTime":357.54,"endTime":360.039,"body":"is A. rheumatoid arthritis"},{"startTime":360.039,"endTime":363.08,"body":"is not associated with an"},{"startTime":360.039,"endTime":363.08,"body":"increased risk of colon cancer."},{"startTime":363.08,"endTime":364.06,"body":"[Dr. Handy] That's right."},{"startTime":364.06,"endTime":366.15,"body":"So just to go through the other answers,"},{"startTime":366.15,"endTime":368.95,"body":"osteoporosis is more"},{"startTime":366.15,"endTime":368.95,"body":"common in patients with RA"},{"startTime":368.95,"endTime":371.99,"body":"than age and sex-matched"},{"startTime":368.95,"endTime":371.99,"body":"population controls,"},{"startTime":371.99,"endTime":375.9,"body":"and the prevalence is about"},{"startTime":371.99,"endTime":375.9,"body":"20-30% in RA patients."},{"startTime":375.9,"endTime":378.08,"body":"We think that the inflammatory"},{"startTime":375.9,"endTime":378.08,"body":"millieu of the joint"},{"startTime":378.08,"endTime":380.4,"body":"probably spills over"},{"startTime":378.08,"endTime":380.4,"body":"into the rest of the body"},{"startTime":380.4,"endTime":382.16,"body":"and promotes generalized bone loss"},{"startTime":382.16,"endTime":384.431,"body":"by activating osteoclasts."},{"startTime":384.431,"endTime":386.07,"body":"Chronic use of glucocorticoids"},{"startTime":386.07,"endTime":387.97,"body":"and disability-related immobility"},{"startTime":387.97,"endTime":391.02,"body":"probably also contributes to osteoporosis."},{"startTime":391.02,"endTime":394.27,"body":"With regards to option"},{"startTime":391.02,"endTime":394.27,"body":"C and hypoandrogenism,"},{"startTime":394.27,"endTime":396.473,"body":"men and post-menopausal women with RA"},{"startTime":396.473,"endTime":399.06,"body":"do have lower mean serum"},{"startTime":396.473,"endTime":399.06,"body":"testosterone levels,"},{"startTime":399.06,"endTime":401.15,"body":"luteinizing hormone, or LH levels,"},{"startTime":401.15,"endTime":405.06,"body":"and DHEA levels compared"},{"startTime":401.15,"endTime":405.06,"body":"to control populations."},{"startTime":405.06,"endTime":407.97,"body":"It has thus been hypothesized"},{"startTime":405.06,"endTime":407.97,"body":"that hypoandrogenism"},{"startTime":407.97,"endTime":410.52,"body":"may play a role in the pathogenesis of RA"},{"startTime":410.52,"endTime":411.929,"body":"or arise as a consequence"},{"startTime":411.929,"endTime":414.25,"body":"of the chronic inflammatory response."},{"startTime":414.25,"endTime":415.94,"body":"[Dr. Wiener] Okay. So"},{"startTime":414.25,"endTime":415.94,"body":"the teaching point here"},{"startTime":415.94,"endTime":418.97,"body":"is that rheumatoid"},{"startTime":415.94,"endTime":418.97,"body":"arthritis plus splenomegaly"},{"startTime":418.97,"endTime":422.33,"body":"plus neutropenia is defined"},{"startTime":418.97,"endTime":422.33,"body":"as Felty's syndrome,"},{"startTime":422.33,"endTime":426.16,"body":"which may have a similar"},{"startTime":422.33,"endTime":426.16,"body":"presentation to the T-cell LGL,"},{"startTime":426.16,"endTime":429.54,"body":"which also occurs in association"},{"startTime":426.16,"endTime":429.54,"body":"with rheumatoid arthritis."},{"startTime":429.54,"endTime":431.91,"body":"Cardiovascular disease,"},{"startTime":429.54,"endTime":431.91,"body":"like the general population,"},{"startTime":431.91,"endTime":434.56,"body":"is the most common cause"},{"startTime":431.91,"endTime":434.56,"body":"of death in RA patients,"},{"startTime":434.56,"endTime":436.39,"body":"and RA patients are at higher risk"},{"startTime":436.39,"endTime":437.97,"body":"of a host of other disorders,"},{"startTime":437.97,"endTime":440.7,"body":"but appear at this point"},{"startTime":437.97,"endTime":440.7,"body":"to not be at increased risk"},{"startTime":440.7,"endTime":443.97,"body":"of many solid tumors,"},{"startTime":440.7,"endTime":443.97,"body":"such as colon cancer."},{"startTime":443.97,"endTime":445.48,"body":"[Dr. Handy] And if you want"},{"startTime":443.97,"endTime":445.48,"body":"to learn more about this,"},{"startTime":445.48,"endTime":447.08,"body":"you can check out Harrison's chapter"},{"startTime":447.08,"endTime":448.862,"body":"on rheumatoid arthritis."},{"startTime":448.862,"endTime":451.279,"body":"[outro music]"},{"startTime":452.94,"endTime":455.79,"body":"[Mr. Shanahan] This is Jim"},{"startTime":452.94,"endTime":455.79,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":455.79,"endTime":457.42,"body":"Harrison's Podclass is brought to you"},{"startTime":457.42,"endTime":459.41,"body":"by McGraw Hill's Access Medicine,"},{"startTime":459.41,"endTime":460.92,"body":"the online medical resource"},{"startTime":460.92,"endTime":462.88,"body":"that delivers the latest trusted content"},{"startTime":462.88,"endTime":464.73,"body":"from the best minds in medicine."},{"startTime":464.73,"endTime":467.263,"body":"Go to accessmedicine.com to learn more."}]}