Report of anti-CCP antibody positive paraneoplastic polyarthritis and review of the literature

Abstract

A 45-year-old female presented to the rheumatology clinic with complaint of pain and swelling of multiple small joints of the hands and feet. She also complained of cough and shortness of breath onset around the same time. Since her cyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor tests were positive, rheumatoid arthritis (RA) was diagnosed and she was started on prednisone with plans for additional disease modifying therapy. Chest X-ray showed a small right pleural effusion. While additional pulmonary evaluation was being planned, a few weeks later she presented with dyspnea, fever and tachycardia. Spiral CT showed pulmonary emboli and increased pleural effusion and patient was started on anticoagulation. A chest tube was placed and exudative pleural effusion was drained. Cytology sample from bronchoscopy raised concerns for adenocarcinoma. Open lung biopsy confirmed moderately differentiated adenocarcinoma. The patient died of lung cancer in the hospital 8 weeks from her diagnosis of RA. We describe a case of paraneoplastic polyarthritis with positive anti-CCP antibody test which has not been reported before. We also review the literature on paraneoplastic arthritis which has been described in association with various other malignancies besides lung cancer.

Paraneoplastic rheumatologic syndromes

“…Paraneoplastic syndromes are the expression of an underlying cancer, frequently occult, and can be caused by a wide variety of remote tumor effects unrelated to the mechanical impact of the tumor mass or distant metastases. Anticyclic citrullinated peptides (CCP) measurement can be useful in this setting [7], although cases of anti-CCP-positive paraneoplastic polyarthritis have also been reported [8,9]. Rheumatic syndromes can be important clues to occult neoplasia [1,2].…”

Interstitial granulomatous dermatitis and arthritis revealing oesophageal carcinoma

“…Onset of RA in people elderly generally has a poor prognosis, with more severe erosive disease and joint damage, which were absent in this case 8 . Although anti‐CCP testing was positive, these antibodies are not pathognomonic for RA, and anti‐CCP‐positive paraneoplastic polyarthritis has been reported previously 9 . Moreover, our patient’s disease was refractory to classic RA treatment, and there was no rheumatoid factor, rheumatoid nodules or any family history of rheumatic diseases.…”

“…8 Although anti-CCP testing was positive, these antibodies are not pathognomonic for RA, and anti-CCP-positive paraneoplastic polyarthritis has been reported previously. 9 Moreover, our patient's disease was refractory to classic RA treatment, and there was no rheumatoid factor, rheumatoid nodules or any family history of rheumatic diseases. Regarding the clinical presentations of IGDA, a wide variability of cutaneous lesions has been described.…”

A can of red herrings

“…Anti‐CCP antibody has been detected in several non‐rheumatic conditions such as hepatitis C infection, autoimmune hepatitis, pulmonary tuberculosis (TB) and more recently paraneoplastic polyarthritis 15–18 . Our patient presented with a paraneoplastic polyarthritis associated with rheumatoid factor and anti‐CCP antibody positivity, mimicking RA.…”

“…Paraneoplastic polyarthritis has been reported in a number of solid tumors including lung, gastric, colon, breast, ovarian, laryngeal and pancreatic tumors associated with rheumatoid factor positivity in ≈ 10–20% of patients 19 . Anti‐CCP antibody positivity in paraneoplastic polyarthritis has only been recognized recently in case reports of metastatic pancreatic cancer and adenocarcinoma of the lung 17,18 . There are no previous reports of anti‐CCP antibody positivity in a lymphoproliferative disease on its own.…”