The Association of Rheumatoid Arthritis with Lichen Amyloidosis: Case Report

Abstract

INTRODUCTION: Rheumatoid arthritis (RA) is a chronic inflammatory disorder with articular and extra-articular manifestations. Extra-articular manifestations are common and occur in almost every organ system. The cutaneous findings of RA are considered as extra-articular manifestations. Sayah et al. divided cutaneous manifestations of RA into two groups: 1) General cutaneous manifestations which are nonspecific skin changes including cutaneous atrophy, palmar erythema, clubbing, and splinter hemorrhages. 2) Specific cutaneous manifestations, namely classic rheumatoid nodules, accelerated rheumatoid nodulosis, rheumatoid nodulosis, rheumatoid vasculitis, felty syndrome, pyoderma gangrenosum, and granulomatous dermatitis. Among the RA related cutaneous manifestations, localized or generalized amyloidosis had not been reported in the literature before. Herein, we present a case of RA associated with lichen amyloidosis. CASE: A 28-year-old woman presented to our clinic with a 3-month history of swelling and pain of small joints of the hands. On physical examination, swelling and tenderness involving bilaterally the wrist, metacarpophalangeal, and proximal phalangeal joints were noted. Dermatological examination revealed hyperpigmented and hyperkeratotic plaques on both elbows, knees, and lateral malleolus. She had a history of morning stiffness lasting for 3-4 hours. She did not report associated alopecia, photosensitivity, oral aphtous ulcers, fever, purpura, petechiae, cough, headache, sputum, dispnea, hyperhidrosis, sleepiness, and chills. Laboratory investigations including complete blood cell count and blood chemistry were within normal limits. C-reactive protein was 6,05 mg/dL, erythrocyte sedimentation rate was 120 mm/hour, and rheumatoid factor was negative. The patient was diagnosed with RA and was started on medical treatment. She was referred to the dermatology department for the evaluation of skin lesions. A punch biopsy specimen was obtained and histopathologic examination disclosed findings consistent with lichen amyloidosis. As lichen amyloidosis can be associated with multiple endocrine neoplasia type 2 (MEN-2), the patient was reevaulated for the presence of MEN-2, however, no pathology was detected. On follow-up, the symptoms of arthritis subsided and the patient was discharged from the hospital. CONCLUSION: It should be kept in mind that, in addition to the most widely recognized skin lesions, lichen amyloidosis can also develop in association with RA.