A 59-year-old teacher presented with a 9-year history of rheumatoid arthritis (RA). She developed severe swelling and pain in joints of hand and feet with deformities (Figure 1A and 1B) despite undergoing ayurvedic treatment for 3 years. During the visit, she reported stiffness in her ankle, knees, and elbows that lasted 1-2 hours every morning.

She had increasing difficulty in standing and walking for long periods at work or at home. She has also complained about dyspnea on exertion.