Mr W, 43 years of age, presented with a 2 year history of arthralgia and diminishing grip strength. He reported mild fatigue but was otherwise healthy. On general examination he appeared well. There was bony swelling over the second and third metacarpophalangeal (MCP) joints of both hands, with mild tenderness and impaired flexion of these joints – producing the ‘iron salute’ (Figure 1). There was no synovitis on peripheral joint examination. Mr W was not pigmented and had no symptoms or signs of liver disease, hypogonadism, cardiac failure or diabetes. A clinical suspicion of haemochromatosis was supported by abnormal iron studies (Table 1). Plain hand radiographs showed only mild joint space narrowing and bony sclerosis in the MCP joints but no osteophytes. HFE genotyping revealed homozygosity for the C282Y mutation. A liver biopsy did not show fibrosis or cirrhosis but confirmed that he had iron overload. Mr W’s first degree relatives were alerted to his diagnosis and tested. Mr W started a course of venesection, however, even after this treatment produced biochemical ‘de-ironing’ (serum ferritin level fell to 19 ng/mL and transferrin saturation level fell to 22%) he continued to experience arthralgia and mild joint restriction.
The presentation of haemochromatosis is typified by abdominal pain, arthralgia and fatigue or weakness.1 Arthropathy may be the major presenting feature. The detection of an osteoarthritis-like process involving the metacarpophalangeal (MCP) and wrist joints in middle aged men should signal the possibi l i ty of under lying haemochromatosis. Other joints such as the shoulder, hip, knee or ankle may be affected. However, the preferential involvement of the second and third MCP joints is striking and may provide the opportunity for early identification of iron overload disease.2 The 'iron salute' can be an efficient screening tool for this MCP joint arthropathy but it is not well known by clinicians.3
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