372: FELTY SYNDROME: A SHROUDED DIAGNOSIS

Abstract

Introduction: Felty syndrome, which can be a complication of rheumatoid arthritis (RA), is often misdiagnosed as other infectious etiologies that cause bone marrow suppression. It is characterized by RA, splenomegaly, and neutropenia. Neutropenia must be present for diagnosis. We present a case of Felty syndrome with an initial presentation of diffuse dermatologic abscesses in a patient with a history of diabetes mellitus and RA. Description: A 58-year-old man with a medical history of RA, diabetes mellitus, and Barrett’s esophagus presented to the emergency department with skin sores on his head, face, arms, and testicle with associated chills. His RA was previously treated with methotrexate, but he discontinued his medication and was lost to follow-up. Upon arrival at the hospital, the patient did not disclose his RA history. Workup revealed normocytic anemia, leukopenia, absolute neutropenia, and lymphocytosis. Infectious Diseases, Hematology/Oncology, and Plastic Surgery were consulted. Wound cultures were positive only for vancomycin-resistant enterococci. He remained neutropenic despite 3 days of filgrastim. Further blood tests revealed a high rheumatoid factor, CCP, ESR, and CRP with normal C3, C4, and SSA. ANA was negative. Rheumatology was consulted and the patient was started on leflunomide with oral prednisone. His absolute neutrophil count began to improve. He was discharged home with leflunomide and oral prednisone with close outpatient Rheumatology follow-up. Discussion: Although uncommon, Felty syndrome presents with profound neutropenia predisposing patients to a multitude of infections, most commonly dermatological and respiratory. A thorough history is important to evaluate for risk factors of Felty syndrome. In this case, a prior history of RA was not initially disclosed by the patient, although it may have been elicited with a specific line of questioning. Felty syndrome is often misdiagnosed on presentation and should be considered in any patient who presents with rheumatoid arthritis and neutropenia. Consultations with Rheumatology, Oncology/Hematology, and Infectious Diseases should be made with haste as any delay in treatment can be fatal. Patients should be closely monitored outpatient with special attention paid to their neutrophil count to prevent future infections.