I met her at the start of 2012. A young lady with a new husband. She presented with a very swollen knee. The diagnosis was rheumatoid arthritis and it was an easy one to make, given she had very raised autoimmune serology (RF and anti-CCP) and her mother also had the disease.
They were trying for a baby so treatment options were limited. And it was just the one joint involved, so treatment was localised to aspiration and cortisone injection.
I think I got to see her three times. Then she disappeared. She cancelled a follow-up appointment, said she'd reschedule, and didn't.
In a busy rheumatology clinic, it's hard to have a good follow-up system for patients who don't want to return. And, I forgot about her.
She's now back. And the rheumatoid is rampant.
Over 21 months since review and she now has over 20 joints involved, both big and small. Her fingers are all deviated at the MCP joints (knuckles), her wrist movements are restricted and her thumbs are shaped like a Z.
The window of opportunity to switch off her rheumatoid is well and truly over. We missed it.
I had a window period to educate her on how serious her disease could potentially become. I missed that.
I figure all rheumatologists would spent a lot of time up front trying to explain this beast called rheumatoid arthritis. I thought I was relatively effective at this but this sort of occurrence brings me back to earth.
Why didn't she return?
Well, she was still trying to fall pregnant. And she thought that as long as she was trying, she couldn't be treated. I suspect she has had difficulty coping with having a chronic disease and just plodded along, accepting her symptoms. Even now in the face of very active, deforming rheumatoid, she tells me she is coping and has little pain.
I feel disappointed and sad at what's happened. Especially as it was likely to have been preventable.