Clinical Summary
Consolidated picture
This document brings together the lab work, imaging, prescription history, and consultations from multiple visits across 2024–2026. The intent is to give any treating doctor a single consolidated picture so a fresh assessment can be made with all the evidence available together.
Diagnosis on record
A formal rheumatoid arthritis diagnosis was made on 18 November 2025 by Dr. Rishabh Nanavati (rheumatologist, MBBS MD General Medicine, Fellowship in Rheumatology at Hinduja Hospital Mumbai, EULAR-certified) following a consultation in Mumbai. The diagnosis was based on strongly positive RF (284), elevated CRP (7.1), elevated ESR (60), and positive anti-CCP. Tab. Leflunomide 20mg was started as DMARD therapy.
Highly Specific Marker
Anti-CCP 77.2 U/mL
September 2025 — strongly positive against a cutoff of 5.0. Anti-CCP is a highly specific marker for rheumatoid arthritis.
Treatment course since the diagnosis
- Leflunomide was taken for approximately one month (Nov–Dec 2025).
- After review (timing not on record), Dr. Nanavati advised stopping Leflunomide on the basis that her predominant complaint at the time was knee-related rather than RA-typical, and referred her to orthopaedic care.
- There has been no rheumatology follow-up since, and no DMARD therapy has been continuous.
- All care from January 2026 onward has been orthopaedic — Dr. Midhun K.M and Dr. Sanjeev P, managing flares with NSAIDs, short steroid courses, episodic HCQ, topical analgesics, and SAMe.
What has been documented since stopping Leflunomide
- 22 Jan 2026 — Dr. Midhun K.M documented right ankle pain and swelling, with clinical suspicion of synovitis.
- 02 Mar 2026 — Dr. Midhun K.M wrote in the chart: "RA (+), Anti-CCP (+), ?Synovial proliferation, ?Soft tissue swelling" and ordered an ultrasound of the right 5th MCP joint.
- 02 Mar 2026 — USG showed a heterogeneous irregular soft-tissue lesion (16 × 12 × 12 mm) at the right 5th metacarpophalangeal joint, with minimal fluid component. Reported as "?Ganglion cyst / ?Fibromatous mass" and MRI was suggested for further evaluation but not done yet.
- 22 Apr & 25 Apr 2026 — Two separate visits to Dr. Sanjeev for severe pain in hands and legs; treated with steroid + NSAID + topical + injectable Ketorolac.
Inflammatory markers across the period
- Anti-CCP: 77.2 U/mL (Sep 2025) — strongly positive (cutoff 5.0).
- Rheumatoid Factor: 270.5 → 284.7 IU/mL (Aug & Nov 2025) — strongly positive.
- ESR: 50 → 40 → 60 mm/hr (Apr 2024, Aug 2025, Nov 2025) — persistently elevated; latest the highest.
- CRP: 7.1 mg/L (Nov 2025) — elevated.
- Haemoglobin: 10.8 → 11.0 → 11.0 gm% — persistently mildly low across 19 months, consistent with chronic-disease anaemia.
Mechanical knee findings
Independent of the inflammatory picture, MRIs document significant structural knee abnormalities:
- Bilateral complete chronic ACL tears (both knees Dec 2025; left knee already showed near-complete tear in Nov 2024).
- Bilateral complex tears in the anterior horn of the lateral meniscus.
- Subchondral cysts in the tibial notch region of both knees.
- Left knee developed "secondary osteoarthritis changes in the overlying condyles" by Dec 2025 — a change from Nov 2024 when articular surfaces were noted as normal.
- Cartilage in both knees overall preserved as of Dec 2025 — meaningful, as it suggests a window before bone-on-bone OA sets in.
Meaningful Change
Left knee, Nov 2024 → Dec 2025: articular surfaces were noted as normal in November 2024. By December 2025, the same knee shows secondary osteoarthritis changes in the condyles overlying the meniscal tear. The trajectory matters more than the snapshot.
What is reassuring
Organ function intact
Kidney (creatinine 0.8–1.0) and liver (SGPT, SGOT, bilirubin, ALP) all normal — she would tolerate standard RA medications well from an organ-safety standpoint.
Common confounders ruled out
Vitamin D sufficient (162 nmol/L), thyroid normal, uric acid normal — these can be set aside as contributors.
Cartilage preserved bilaterally
There's still time to protect the joints before bone-on-bone changes emerge.
Tolerates current medications
NSAIDs, steroids, HCQ, and one month of Leflunomide tolerated without abnormal liver/kidney changes so far.
Open questions a treating doctor may find useful
- Should rheumatology follow-up be re-engaged, particularly in light of the March 2026 right 5th MCP USG finding (small joint involvement) which post-dates the decision to stop Leflunomide?
- The MRI of the right 5th MCP (suggested by the USG report) was not done. Should it be done now?
- Given the continuing flares (Jan 2026, Apr 2026 ×2), the persistently elevated ESR/CRP, and the new small-joint finding — does the case for resuming continuous DMARD therapy need to be revisited?
- Could the bilateral, symmetric, atraumatic ACL and lateral meniscal tears reflect ligamentous involvement from chronic inflammation, or are they purely degenerative?
- Is there value in an MRI or ultrasound of the right ankle to characterize the synovitis seen clinically in January 2026?
- Would iron studies and B12 testing be worth doing to fully characterize the persistent mild anaemia?
- What is the role of physiotherapy and quadriceps strengthening, given the preserved cartilage and torn ACLs?
Notes on current approach
She is currently being managed by orthopaedic doctors with episodic NSAIDs, short steroid courses, episodic HCQ, topical analgesics, and SAMe. She is also planning to attend an Ayurvedic retreat for pain management. Any treating doctor reviewing this file is welcome to advise on how best to integrate her current preferences with the clinical picture above.
Laboratory
Lab results
Tracked across four visits between April 2024 and November 2025. Values shown in red are outside the reference range. "—" means the test was not done on that date.
Inflammation & Autoimmune Markers
most clinically significant
| Test | Apr 2024 | Aug 2025 | Sep 2025 | Nov 2025 | Reference |
|---|
| ESR | 50 | 40 | — | 60 | 0–15 mm/hr |
| CRP (Turbilatex) | — | — | — | 7.1 | <6 mg/L |
| Rheumatoid Factor | — | 270.5 | — | 284.7 | 0–30 IU/mL |
| Anti-CCP (CLIA) | — | — | 77.2 | — | <5.0 U/mL |
Haematology
chronic-disease anaemia pattern
| Test | Apr 2024 | Aug 2025 | Nov 2025 | Reference |
|---|
| Haemoglobin | 10.8 | 11.0 | 11.0 | 11.5–16 gm% (F) |
| Total WBC Count | 6,100 | 6,200 | 7,200 | 5,000–10,000 /cumm |
| Neutrophils | 55 | 57 | 55 | % |
| Lymphocytes | 41 | 38 | 40 | % |
| Eosinophils | 4 | 5 | 5 | % |
| Platelet Count | 2,28,000 | — | 2,70,000 | 1.5–4.0 lakh /cumm |
Biochemistry
all within range
| Test | Apr 2024 | Aug 2025 | Nov 2025 | Reference |
|---|
| Fasting Blood Sugar | 90 | 80 | — | 70–110 mg/dl |
| Postprandial Blood Sugar | 128 | 120 | — | 60–160 mg/dl |
| Fasting Urine Sugar | — | Not Detected | — | — |
| Uric Acid | — | 4.1 | — | 2.4–5.7 mg/dL (F) |
| Serum Calcium | — | 9.4 | — | 9–11 mg/dL |
Liver Function
normal — tolerates DMARDs
| Test | Aug 2025 | Nov 2025 | Reference |
|---|
| Total Protein | 6.6 | — | 6.0–8.0 gm/dl |
| Albumin | 3.7 | — | 3.5–5.5 gm/dL |
| Globulin | 2.9 | — | 2.3–3.6 gm/dl |
| A/G Ratio | 1.28:1 | — | 1.0–2.3 |
| Total Bilirubin | 0.8 | — | 0.2–1.0 mg/dl |
| Direct Bilirubin | 0.3 | — | mg/dl |
| Indirect Bilirubin | 0.5 | — | mg/dl |
| SGOT | 29.7 | — | 5–46 U/L |
| SGPT | 25.2 | 20.6 | 5–49 U/L |
| Alkaline Phosphatase | 90.3 | — | 42–141 U/L |
Renal Function
normal — tolerates DMARDs
| Test | Aug 2025 | Nov 2025 | Reference |
|---|
| Blood Urea | 27.2 | — | 10–50 mg/dl |
| Serum Creatinine | 0.8 | 1.0 | 0.6–1.4 mg/dl |
Lipid Profile
borderline cholesterol
| Test | Apr 2024 | Aug 2025 | Reference |
|---|
| Serum Cholesterol | 206 | 220 | 150–200 mg/dl |
| Serum Triglycerides | 120 | 130 | 65–170 mg/dl |
| HDL | 55 | 54 | >40 mg/dl |
| LDL | 127 | 140 | <130 mg/dl |
| VLDL | 24 | 26 | 5–40 mg/dl |
| SC/HDL Ratio | 3.7 | 4.1 | <5 |
| LDL/HDL Ratio | 2.3 | 2.6 | <3 |
Thyroid & Vitamins
normal — confounders ruled out
| Test | Apr 2024 | Aug 2025 | Nov 2025 | Reference |
|---|
| TSH | 2.11 | 2.55 | — | 0.3–4.5 µIU/mL |
| T3, Total | — | 1.07 | — | 0.60–1.81 ng/mL |
| T4, Total | — | 6.60 | — | 4.50–11.60 µg/dL |
| Vitamin D 25-Hydroxy | — | — | 162.25 | 75–250 nmol/L |
Urinalysis
28 Aug 2025 · normal
Clear, pale yellow, acidic. Albumin nil. Sugar not detected. Bile pigments/salts nil. Pus cells 1–2/hpf (normal). Red cells nil. Epithelial cells 2–3/hpf. Bacteria nil. Casts nil.
Test sources —
Apr 2024: Micro Clinical Laboratory, Cherpu (Ref: Dr. P.K. Bhaskaran) + Polyclinic Pvt Ltd, Thrissur (TSH).
Aug 2025: Micro Clinical Laboratory, Cherpu (Bill: MCL153596) + Dr Lal PathLabs via LPL-Cochin (Thyroid Profile).
Sep 2025: Mediwave Diagnostic Centre, Andheri (W), Mumbai (Anti-CCP).
Nov 2025: Micro Clinical Laboratory, Cherpu (Bill: MCL155331) + Dr Lal PathLabs via LPL-Cochin (Vitamin D).
Imaging
Imaging findings
Three knee MRIs and one ultrasound of the right hand. The December 2025 left knee shows a meaningful change from November 2024 — early secondary OA changes in the condyles where there were none thirteen months earlier. The March 2026 USG of the right 5th MCP documents a soft-tissue lesion that has not yet been further evaluated by MRI.
26 November 2024 · MRI Left Knee
Elite Mission Hospital, Thrissur
Ref: Dr. Hareesh.P, MBBS D(Ortho) · Reported: Dr. Prathap T.V, MD (Consultant Radiologist) · Multiplanar Multiecho NCEMRI · Clinical details: Pain left knee
Findings
- Joint space: Normal
- Lateral meniscus: complex tear in anterior horn extending to body; Grade II signal in posterior horn
- Medial meniscus: Normal
- ACL: lax with near complete tear in distal third; edema with intrasubstance linear hyperintensity; small linear cyst in proximal third
- PCL: Intact and buckled
- Joint effusion: None
- Femoral condyles & tibial plateau articular surfaces: Normal
- Contusions posterolaterally in lateral tibial condyle
- Focal contusion in lateral facet of patella near lower pole; rest of patella, patellar ligament, retinaculum normal
- MCL & LCL: Normal · surrounding muscles, neuromuscular bundle, periarticular soft tissues: Normal
Impression
- Complex tear in anterior horn of lateral meniscus extending to body; Grade II signal in posterior horn
- Laxity of ACL with near complete tear in distal third and linear interstitial tears
- Buckled PCL
- Mild focal contusions posterolaterally in tibia and near lower pole of patella
14 December 2025 · MRI Right Knee
Elite Mission Hospital, Thrissur
Ref: Dr. Rishabh Nanavati · Reported: Dr. K.C. Pyarelal, MD (Consultant Radiologist) · GE Signa 1.5T Ultrafast MR 30 · 3D AIR Recon DL (AI)
Findings
- Marrow: subchondral cysts in tibial notch region
- Effusion: None · Medial meniscus: Normal
- Lateral meniscus: complex tear of anterior horn
- ACL: complete tear
- PCL: Buckled but intact
- MCL, LCL, popliteofibular ligament, posterolateral corner ligaments, popliteal tendon, ITB: All normal
- Quadriceps tendon: Normal
- Patella: subchondral edema in lateral aspect
- Patellar tendon, Hoffa's fat pad: Normal
- Cartilages (PFJ, medial, lateral compartment): All normal
Impression
- Complete tear of anterior cruciate ligament
- Complex tear in anterior horn of lateral meniscus
- Subchondral cysts in tibial notch region
- Subchondral edema in lateral aspect of patella
14 December 2025 · MRI Left Knee
Elite Mission Hospital, Thrissur
Ref: Dr. Rishabh Nanavati · Reported: Dr. K.C. Pyarelal, MD (Consultant Radiologist) · GE Signa 1.5T Ultrafast MR 30 · 3D AIR Recon DL (AI)
Findings
- Marrow: subchondral cyst in tibial notch region
- Effusion: None · Medial meniscus: Normal
- Lateral meniscus: complex tear in anterior horn — with secondary osteoarthritis changes in the overlying condyles
- ACL: complete tear
- PCL: Buckled but intact
- MCL, LCL, popliteofibular ligament, posterolateral corner ligaments, popliteal tendon, ITB: All normal
- Quadriceps tendon, patella, patellar tendon, Hoffa's fat pad: All normal
- Cartilages (PFJ, medial, lateral compartment): All normal
Impression
- Complete tear of anterior cruciate ligament
- Complex tear in anterior horn of lateral meniscus with secondary osteoarthritis changes in overlying condyles
- Subchondral cyst in tibial notch region
Change since Nov 2024
Articular surfaces were noted normal then; now showing early secondary OA changes in the condyles overlying the meniscal tear.
02 March 2026 · USG Soft Tissue, Right 5th MCP
Manappuram MAcare Diagnostics
Ref: Dr. Midhun K.M · Reported: Dr. Geoffrey Kochery, MBBS DMRD (Reg No: 32937)
Findings
- Right 5th metacarpophalangeal region shows a heterogeneous irregular area approximately 16 × 12 × 12 mm
- Minimal fluid component seen
- No calcification or vascularity seen
- No significant tendon abnormality detected
- Underlying osseous structures appear normal
Impression
- Right 5th MCP region lesion — ?Ganglion cyst / ?Fibromatous mass
- MRI suggested for further evaluation
Follow-up not done
The MRI suggested by this report has not been performed.
Consultations
Rheumatology consultation
One formal rheumatology consultation on record — at which the rheumatoid arthritis diagnosis was made. No rheumatology follow-up has occurred since Leflunomide was stopped in December 2025.
18 November 2025 · Dr. Nanavati's Centre for Rheumatology, Vile Parle West, Mumbai
Dr. Rishabh Nanavati, Rheumatologist
MBBS, MD (General Medicine) · Fellowship in Rheumatology, Hinduja Hospital, Mumbai · EULAR-certified · Affiliated: Nanavati Super Speciality Hospital, Sir H.N. Reliance Foundation Hospital, Healthsmart Medical Centre (Ghatkopar)
Reports noted by clinician
- RF: 284
- CBC: Normal
- CRP: 7.1 (>6)
- Creatinine: 1.0 (<1.4)
- SGPT: 20.6 (<49)
- ESR: 60
Clinical note
- Both knees — at times needs to drag the leg
Diagnosis
- RA (Rheumatoid Arthritis)
Plan
- Next consult in 2 months · SOS MRI knees
| Medication | Class / Purpose | Dose & Schedule |
|---|
| Tab. Lefra 20mg | Leflunomide (DMARD) | 1-0-0 |
| Tab. Ryout New | Anti-gout / uric acid agent (name to be verified) | 1-0-0 |
| Tab. Evion LC | Vitamin E + L-Carnitine | 1-0-1 × 4 weeks, then 1-0-0 × 4 weeks |
| Tab. CCM 500mg | Calcium + Calcitriol + Magnesium | 0-0-1 |
| Tab. Acenac-P | Aceclofenac + Paracetamol (analgesic) | SOS |
Subsequent course — Patient took Leflunomide for approximately one month. Dr. Nanavati subsequently advised stopping Leflunomide on the basis that her predominant complaint at the time was knee-related rather than RA-typical, and referred her to orthopaedic care. No rheumatology follow-up since.
Prescriptions
Prescription history
Initial RA treatment plan in November 2025; orthopaedic management since January 2026 — episodic NSAIDs, short steroid courses, and short HCQ courses during pain flares.
18 November 2025 · Dr. Rishabh Nanavati (Rheumatologist)
Initial RA treatment plan
See Consultations section above for full details · Leflunomide 20mg + supportive medications · Leflunomide taken for ~1 month then stopped on doctor's advice
22 January 2026 · Manappuram Super Speciality Polyclinic
Dr. Midhun K.M, MBBS MS Ortho
Fellowship Joint Replacement & Arthroscopy · TCMC: 47653
| Medication | Class / Purpose | Dose & Schedule |
|---|
| Tab. Defry 6mg | Deflazacort (steroid) | 1-?-1 × 3 days, then 1-0-0 × 3 days |
| Tab. Etoshine MR | Etoricoxib + muscle relaxant (NSAID combo) | 1-0-0 × 7 days |
| Inj. Ketanov 1ml | Ketorolac (injectable analgesic) | IM, stat dose |
02 March 2026 · Manappuram Super Speciality Polyclinic
Dr. Midhun K.M, MBBS MS Ortho
TCMC: 47653 · Order for investigation, not medication
- Ordered USG of right 5th metacarpophalangeal joint
- Clinical note: RA (+), Anti-CCP (+), ?Synovial proliferation, ?Soft tissue swelling
22 April 2026
Dr. Sanjeev P, MBBS MS Ortho DNB Ortho
Reg No: 50322
| Medication | Class / Purpose | Dose & Schedule |
|---|
| Renato MOM gel | Topical analgesic | Topical application |
| Tab. (name unclear) 6mg | Likely Deflazacort (steroid) | 1 at noon × 5 days |
| Tab. Indocros SR | Indomethacin SR (NSAID) | ½ tablet at bedtime |
| Tab. SAMO 500mg | S-adenosyl methionine (SAMe) | 1 morning + 1 night × 30 days (1000 mg/day) |
| Tab. HCQ 200mg | Hydroxychloroquine (DMARD) | 1 at night × 5 days |
| Item #6 | Illegible | — |
25 April 2026 · Manappuram Super Speciality Polyclinic
Dr. Sanjeev P, MBBS MS Ortho DNB
Reg No: 50322 · Prescribed by proxy (mother present, patient not seen)
| Medication | Class / Purpose | Dose & Schedule |
|---|
| Inj. Ketanov 1 amp | Ketorolac (injectable NSAID analgesic) | IM, stat dose |