Felty’s Syndrome Presenting with Massive Splenomegaly and Pancytopenia: A Diagnostic and Management Challenge

Abstract

Felty’s Syndrome (FS) is a rare, serious complication of long-standing seropositive rheumatoid arthritis (RA), classically characterized by the triad of RA, splenomegaly, and neutropenia. We report the case of a 62-year-old female with a history of RA since 2015, who presented with a one-month history of fever, abdominal discomfort, profound weakness, and significant weight loss. Clinical examination revealed massive splenomegaly. Laboratory investigations confirmed severe pancytopenia with absolute neutropenia. Extensive workup, including bone marrow aspiration-biopsy showing reactive hyperplasia and an 18F-FDG PET-CT scan which ruled out malignancy, confirmed the diagnosis of FS. Management involved supportive care with granulocyte colony-stimulating factor (G-CSF) to address life-threatening neutropenia and the initiation of low-dose methotrexate as foundational disease-modifying therapy. This case highlights the diagnostic challenge FS presents, necessitating exclusion of malignancies and other causes of cytopenias, and highlights the structured, multidisciplinary therapeutic approach required, balancing immunomodulation against the risks of infection in a neutropenic patient.