A 47-year-old homemaker presented with sudden weakness in her right upper limb, later diagnosed with rheumatoid arthritis and interstitial lung disease. Her treatment included methotrexate, which was stopped due to side effects, and she currently remains on salfasalazine and leflunomide. Imaging revealed a mass in the left parietal region suggestive of glioblastoma multiforme, alongside her existing conditions.

1. Presented by-
Dr. Jheelam Biswas
Resident, Phase A, Palliative Medicine
Orchid unit (Internal Medicine)

2.  Mrs. Rashida
 47 years
 Married
 Homemaker
 Hobiganj
 Admitted on 5/9/18

3.  Weakness of right upper limb for 2 weeks

4.  Weakness of right upper limb for 2 weeks which was-
 Sudden onset
 Started with tingling and numbness of fingers, then
gradually progressed over last 5 days to whole of the
right upper limb
 Not associated with pain or sensory loss
 No history of neck pain, trauma, headache, fever or
weakness of any other parts of her body.

5.  No difficulty in speech and swallowing
 No bowel or bladder involvement
 Non diabetic
 Normotensive
 She visited a local doctor who advised for NCS of
Rt. Median nerve and managed conservatively.
 As her condition did not improved, she was
referred to BSMMU.

6.  Pain and swelling of multiple joints for 4 years which-
-Involved MCP, PIP, wrists, elbow joints, ankle,
metatarso-phalangeal joints
-Bilateral symmetrical
-Inflammatory in nature
-Morning stiffness >1 hour
 She visited was labeled as a case of rheumatoid arthritis
on the basis of clinical criteria by local physician and
was given some medications that she could not
mention.

7.  She was on irregular medication and follow up.
 She visited an internist 1 year back and was put on
Methotrexate, Indomethacin and Deflazacort for 3
months.
 Her pain and swelling decreased.
 She developed dry cough and breathlessness 3
months after starting treatment.

8.  HRCT of chest was done and found to have B/L ILD
with bronchiactatic changes.
 Methotrixate was stopped.
 Currently she is on
- Salfasalazine
-Leflunomide for 1 year
 She is on remission for 1 year

9.  Tab. Salfasalazine (500mg)- 2+1+2
 Tab. Leflunomide (10mg)- 0+0+2

10.  Married for 22 years with no living child
 No family history of DM, HTN, RA, Br. Asthma
Obstetric and gynecological
history
 Menopausal for 3 years
 History of abortion at 12 weeks 10 years back

11.  She is from a lower middle class family
Immunization history
 Vaccinated with BCG vaccination

12.  Pulse- 78 b/min
 Bp- 110/80 mmHg
 Temp- 98F
 Resp. rate-16 b/min
 Swan neck deformity in Rt little finger, Lt index and
4th finger, lateral deviation of toes in Rt foot.
 No anemia, jaundice, cyanosis, edema, clubbing,
koilonichia, leuconychia, thyromegaly,
lymphandenopathy.

13.  Higher cerebral function- normal
 Cranial nerves- intact
 Motor system-
- Muscle power MRC grade 1in Rt upper limb
- Tone- reduced in Rt upper limb
- No wasting or fassiculation
- All jerks are normal.
-Planter- equivocal on Rt. side
 Sensory- intact
 Fundoscopy- Normal
 Signs of meningeal irritation- absent

14.  Hand
-Swan neck deformity in Rt little finger, Lt index
and 4th finger.
- No tender or swollen joints or Rheumatoid
nodules
 Foot - Lateral deviation of toes in Rt foot.
 Spine- Normal
 Gait- Normal

15.  B/L fine crepitation present in lower zone of both
lungs, more marked on Rt lung
 Not altered by cough

16.  Rheumatoid arthritis with DPLD with
monoplegia due to-
 Mononeuritis Multiplex
 Cervical myeloradiculopathy
 Acute stroke
 ICSOL

17. 25/5/2017 10/9/18
Hb 10.6 g/dl 13.4 g/dl
ESR 55 mm/1st hr 20 mm 1st hr
WBC 4500/ cumm 10800/cumm
MCV 78 fl 86.0fl
PBF Non specific findings

18. 25/5/17 6/9/18
Anti CCP antibody >200 U/ml (positive) 1108 U/ml
CRP 12 mg/L (positive) <3.2 mg/L (negative)
SGPT 17 U/L 20 U/l
S creatinine 0.8 mg/dl 0.69 mg/dl
RBS 5.8 mmol/L 6.4 mmol/l
S. electrolyte Na- 136 mmol/l
K- 3.7 MMOL/L
Urine R/E PC-10-15 HPF
Anti phospholipid Ab negative

19. Fine
reticulonodular
shadow in lower
zone of rt. lung

21.  Suggestive of B/L interstitial lung disease
with bronchiectatic change, more marked in
lower lobes of both lungs.

22. • Cervical lordosis
straightened
• Osteophyte in C5,
C6 level
• Rudimentary
cervical rib on left
side

25.  T1W1 shows mixed signal intensity mass
(3.5*2.7*3.3 cm) in left parietal region.
 On contrast thick irregular rim enhancement with
central interlesional necrosis.
 Huge perifocal edema seen in T2 film.
 3rd and left lateral ventricles are compressed by
the tumor.
 Impression: ICSOL in left parietal region, possibly
Glioblastoma Multiforme.

26.  ICSOL in left parietal region with RA with
DPLD.