A 66-year-old Bangladeshi woman with a 10-year history of rheumatoid arthritis (RA) presented with acute sharp rib and upper back pain of 2 weeks’ duration. This was aggravated by movement and relieved by rest, without preceding trauma. Her RA was previously diagnosed based on the physical findings of active synovitis of her metacarpophalangeal, knees, ankles and metatarsophalangeal joints associated with high titre rheumatoid factor (RF) of 251 IU/ml, erythrocyte sedimentation rate (ESR) 32 mm/hr and C-reactive protein (CRP) 13 mg/L. Previous DMARD therapy included methotrexate, sulfasalazine and leflunomide. She had long standing microcytic anemia (baseline Hb10.2g/dL) attributed to compound heterozygosity for haemoglobin E and sickle cell (HbSE) confirmed on haemoglobin electrophoresis. Previous investigations also showed a negative Direct Coombs test and a reactive bone marrow with erythroid hyperplasia on bone marrow examination.
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