Atypical Extra-articular Manifestations in Rheumatoid Arthritis: A Case of Misdiagnosed Multifocal Tuberculosis

Abstract

Introduction: Rheumatoid arthritis (RA) is the most common auto-immune inflammatory disease. Atypical extra-articular manifestations may obscure the diagnosis when they present as the initial symptoms. Case Presentation: A 58-year-old male patient, with dyslipidemia and coronary artery disease, presented with bilateral granulomatous panuveitis and recurrent nodular scleritis. He was initially diagnosed with multifocal tuberculosis based on presumptive findings, including hypercalcemia, subrenal aortitis, unilateral sacroiliitis with infiltration of the soft parts and a positive tuberculin skin test (21 mm). He was treated with anti-tuberculous therapy and corticosteroids. A favorable response was initially noted. However, three years later, the patient presented with scléromalacie, extension of the aortitis and bilateral sacroiliitis. The final diagnosis was a complex and atypical form of rheumatoid arthritis. High doses of corticosteroids were initiated with the consideration of infliximab biotherapy.  Two months later, the patient presented a sudden unexpected death probably related to a fatal myocardial infarction. Conclusion: This case report highlights the importance of considering RA in differential diagnoses, even when initial symptoms suggest other conditions like tuberculosis. Thus, this case illustrates the diagnostic, therapeutic and prognostic challenges posed by atypical presentations of RA.