This post is an answer to the Case – Swelling of the Hands
A 45-year-old man presented to the rheumatology outpatient unit with bilateral swelling of the hands from the proximal segments of the fingers to the wrist that developed gradually over the past 3 years.
The edema was non-pitting and was not affected by raising the hands. Function of the hands and fingers was not impaired. He had no generalised or pretibial oedema. The patient reported drinking 1–1,5 L of wine per day; medical history was otherwise unremarkable.
Blood tests and an ultrasound scan confirmed hepatitis (alanine aminotransferase [ALT] 175 IU/L, aspartate aminotransferase [AST] 170 IU/L, albumin 4,68 mg/dL) with a positive antibody test for hepatitis C virus; hepatitis B virus and HIV tests were negative. Rheumatoid factor was 29 IU/mL (normal <14 IU/mL); anti-nuclear antibodies, anti-citrullinated peptide antibodies, complement, protein electrophoresis, and total bilirubin were normal.
On further questioning he admitted that he had been injecting high-dose sublingual buprenorphine for more than 5 years, preferentially in the wrist either into or around the veins, three to four times a day.
