A 68 year Old Woman With Rheumatoid Arthritis Presents With Swollen Ankles

A 68 year old woman who was diagnosed with rheumatoid arthritis about 20 years ago now presents with swollen ankles and edematous feet. Her rheumatoid arthritis was relatively well controlled with non steroidal anti inflammatory drugs until six months ago when her symptoms of pain and swelling needed the addition of penicillamine. Patient also has a history of hypertension controlled with drugs.
On examination she has symmetric joint deformities consistent with long standing rheumatoid arthritis. The picture of her hands is shown below:

Her heart rate was 90 beats/min and irregular. Her blood pressure was 140/90 mm Hg. JVP was not raised and her heart sounds were normal and chest was clear on auscultation.
Inspection of the lower limbs reveal pitting edema. Picture is shown below:

 On investigation urinalysis shows +++ proteinuria.

What is the cause of her edema and what will be the management??

.
.
.
Answer:
The patient has heavy proteinuria and gives a recent history of swollen ankles after starting penicillamine six months back. The most likely diagnosis is penicillamine induced membranous nephropathy, which usually occurs within 6-12 months of starting penicillamine.
The patient should be stopped penicillamine as in almost all patients proteinuria resolves after stopping the drug but it may sometimes take several months to improve completely.
Renal amyloidosis is a rare complication of chronic rheumatoid arthritis and it is possible that in the above mentioned patient this may be the cause of proteinuria and edema it is less likely given the history of recent use of penicillamine.