Dual Antibody Positive Rheumatoid Feet - Journal of Brown Hospital Medicine Vol. 5 - Issue 1 - Abstract

Sep 28, 2026

An 86-year-old man with dual antibody positive rheumatoid arthritis presented with severe, progressive deformities affecting both upper and lower extremities, beginning in the forefoot and advancing to the mid and hindfoot over more than twenty years. Examination showed marked hallux valgus, traumatic pes planus, metatarsal head subluxation, and claw and hammer toes, with escalating pain, joint destruction, and gait limitation. Disease progression was linked to ongoing tobacco exposure and intolerance to multiple targeted DMARDs. Management ultimately used hydroxychloroquine and methotrexate with prednisone for flares.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Article Information

Submission and Publication Timeline

Keywords

Case Summary and Clinical Course

Presentation and History of RA

Medication Intolerance and Treatment Sequence

Evolution of Foot and Toe Deformities

Imaging and Physical Exam Findings

Disease Severity and Implications

Images in Hospital Medicine Dual Antibody Positive Rheumatoid Feet Michael E. Lazarus, MD1, Tyler B. Larsen, MD1, Jason D. Napolitano, MD1, Estebes A. Hernandez, MD1 1 Department of Medicine, University of California, Los Angeles Journal of Brown Hospital Medicine Vol. 5, Issue 1, 2025 Article Information Keywords: Dual antibody positive, rheumatoid arthritis, Hammer toe, Hallux Valgus, claw toe, ankle fusion, rheumatoid factor., anti-citrullinated protein antibody [https://doi.org/10.56305/001c.151458](https://doi.org/10.56305/001c.151458) Submitted: November 15, 2025 EST Accepted: November 30, 2025 EST Published: January 01, 2026 EST Abstract An 86-year-old man presented with severe, debilitating, dual antibody positive rheumatoid arthritis associated joint deformities of his upper and lower extremities. These developed over twenty years but were progressive and debilitating. They began in the forefoot and eventually progressed to mid and hindfoot bilaterally. Examination of his lower extremities revealed severe bilateral hallux valgus deformities, traumatic pes planus deformity, right foot metatarsal head subluxation, and bilateral claw and hammer toes. Relentless progression of his lower extremity pain, joint destruction and significant gait limitation was due to a constellation offactors including ongoing tobacco use, dual antibody positivity and intolerance based on side effects to multiple targeted biologic disease-modifying antirheumatic (DMARD) medications including infliximab, etanercept, golimumab and tofacitinib. An 86-year-old man with a greater than twenty-year history of rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) positive erosive rheumatoid arthritis (RA), presented to the emergency department with gait instability and a mechanical ground-level fall. He had fallen on prior occasions due to severe bilateral joint deformities of his legs and feet. He was diagnosed with RA at age sixty-five and was started on methotrexate and infliximab. This was stopped after he developed a pulmonary aspergilloma. After a wedge resection of the lung lesion, he was prescribed etanercept monotherapy. This was eventually switched to golimumab because he was having difficulty with weekly self-injections. Golimumab was discontinued after two years due to a lack of efficacy and disease progression in the upper and lower extremities. A combination of sulfasalazine and tofacitinib was then tried, and he was eventually switched totofacitinib monotherapy due to cytopenia. This regimen was discontinued after three years due to ongoing headaches and a dry cough. Eventually settling on a final regimen of hydroxychloroquine 200mg daily and methotrexate (MTX) at 12.5 mg every week. Episodes of epistaxis at higher MTX doses limited dose escalation. In addition, oral prednisone tapers for significant disease flares were prescribed. The first lower extremity joint abnormality noted was bilateral hallux valgus deformity. This began at diagnosis and had progressed significantly by year five. Metatarsophalangeal (MTP) joint subluxation began later and affected the right foot more than the left. The second through fifth toes began crowding laterally later in his disease course and were associated with splaying of the fore- Figure 1. Leg and foot images demonstrate bilateral chronic hemosiderin exudation on shins and ankles, crowding ofall toes, hallux valgus deformity of both great toes, hammer and claw toes involving digits 2, 3 & 4, traumatic bilateral pes planus, and right foot metatarsal head subluxation. foot seen on Xray. Hammer and claw toes developed after the first decade post-diagnosis and correlated closely with worsening pain, gait instability, and frequent falls. Surgical history included total right hip arthroplasty after a ground-level fall associated with a hip fracture four years ago. He had an elective right ankle fusion two years prior for right ankle instability and associated

FAQs

What deformities were present in the patient’s feet and how did they progress?

He developed severe bilateral hallux valgus and traumatic pes planus, with metatarsal head subluxation and multiple hammer and claw toes. Deformities began in the forefoot at diagnosis and progressed over time to involve the mid and hindfoot bilaterally, worsening pain and gait stability.

Why did the patient’s rheumatoid arthritis progress despite treatment and follow-up?

He did not tolerate multiple targeted biologic DMARDs due to significant side effects. The intolerance, combined with ongoing tobacco use and dual antibody positivity, was associated with ongoing joint inflammation, destruction, and functional decline.

What medications and long-term regimen were used at the end of the case course?

He ultimately settled on hydroxychloroquine 200 mg daily and methotrexate 12.5 mg weekly, with oral prednisone tapers for significant flares. Prior targeted agents were stopped due to adverse effects, lack of efficacy, or disease progression.

Sep 28, 2026

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