PMC4323387_01
X-ray of bilateral fingers and wrists at the diagnosis: A)
erosions with deformity of the carpal bones in the hands,
B)
Left wrist demonstrating bone erosion (black arrow) and joint narrowing partially ankylosis and subluxation of the carpal bones (white arrow).
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PMC4323387_01_40064_2015_798_Fig1_HTML.jpg
Fig1
X-ray imaging showed particular bone erosions in the carpal bones of the hands and partially ankylosis of the carpal bones (Figure 1).
Computed tomography (CT) from cervical to abdomen: A)
and
B)
cervical lymph nodes swelling (
arrows
),
C)
hepatosplenomegary (
arrow heads
).
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PMC4323387_01_40064_2015_798_Fig2_HTML.jpg
Fig2
Evaluation of diagnosis with computed tomography (CT) and ultrasonography showed cervical and mediastinal lymph node swelling, multiple nodules measuring up to 13 mm in diameter in the lungs and mild hepatosplenomegary (Figure 2).
Immunohistochemistry of inguinal lymph node: A)
Hematoxylin and eosin stain (H&E stain) (
x
40 magnification),
B)
Immunostaining shows positive with anti-CD 20 antibody (
x
400 magnification), 
C)
H&E staining in high power field shows proliferations of the full range of diffuse lymphatic cells and phagocytic macrophages included condensed small nuclear cells (
arrows)
suggested the presence of apoptotic cells (
x
400 magnification),
D)
Lymphatic cells are frequently positive with cleaved caspase 3 (
x
400 magnification).
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PMC4323387_01_40064_2015_798_Fig3_HTML.jpg
Fig3
An inguinal lymph node biopsy staining with hematoxylin and eosin staining (H&E staining) showed proliferation of the lymphatic cells without tumor cell phenotype (Figure 3A) and immunohistological studies with this examined inguinal lymph node revealed the lympho-proliferative CD20 positive cells (Figure 3B). H&E staining in high power filed showed the full range of mature lymphatic cells with polymorphous pattern and phagocytic macrophages included condensed small nuclear cells suggested apoptotic cell (Figure 3C). Besides, many lymphatic cells in the inguinal lymph node were positive with cleaved caspase 3 staining (Figure 3D).
Changes in inflammation and disease activity: A)
CRP & ESR,
B)
MMP-3, Clinical course and the treatment showed that the inflammation and disease activity were improved after terminating of the MTX and ADA and administrating the steroid pulse treatment.
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PMC4323387_01_40064_2015_798_Fig4_HTML.jpg
Fig4
Moreover, 10 days treatment with methylprednisolone reached to the complete remission of arthritis with below detection limits in ESR (3 ~ 11 mm/h), CRP (<0.3 mg/dl), and low level of MMP-3 (17.3 ~ 59.7 ng/ml) (Figure 4A and B).