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A 45-year-old Hispanic male physician, a nonsmoker, presented with crippling, nonerosive, seropositive, symmetrical polyarticular arthritis that involved his wrists, hands, elbows, knees, and feet. Findings included an erythrocyte sedimentation rate (ESR) of 114 mm/h (normal, lower than 23 mm/h) and a weakly positive anti–cyclic citrullinated peptide antibody result. The patient had a history of migraine and tinnitus. He had a previous diagnosis of serous otitis media with middle ear and mastoid effusions on CT scanning; he responded initially to antibiotic and corticosteroid therapy.

A diagnosis of rheumatoid arthritis (RA) was made, and the patient was treated with oral methotrexate(Drug information on methotrexate) and self-injected etanercept(Drug information on etanercept). His inflammatory arthritis with disabling musculoskeletal symptoms resolved. However, in spite of a rapid taper of low-dose prednisone(Drug information on prednisone) early in the disease course, the patient continued to self-prescribe various doses of corticosteroids for worsening headache and tinnitus; all symptoms were relieved.