52 yo Hispanic Female - CCP (+) and D-dimer (+), U/S Leg negative

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I have a confusing patient that I'm not sure where to go with.52 yo Hispanic Female.Left ankle pain - negative xray, no specific trauma.Saw Ortho - got MRI which was negative. Placed in a boot with slight improvement, but still painful.

MRI Left Ankle w/o Contrast 11/10 showed 1. Degenerative marrow edema at the talar dome with no osteochondral defect. 2. Degenerative marrow edema the talar neck versus stress reaction and degenerative osteoarthritis of the subtalar joint with no acute bony lesion. 3. No ligament or tendon tear. 4. Diffuse superficial subcutaneous soft tissue edema. 2nd opinion from another Ortho specializing in Ankle/Foot -- rec'd rheum, TB workup.PPD negative. ANA negative, but CCP (Cyclic Citrullinated Peptide Antibody) very positive at 250 (>=60 is considered strongly positive).

See... http://www.rheumatology.org/publications/hotline/1003anticcp.aspRF Quant pending -- some sources recommend checking Rheum Factor with the (+) CCP.

No other joint aches and pains to speak of and no ulnar deviation of MCP joints of hands -- no xray done.Sed Rate 51.Now presents with mild left lower leg pain and swelling of the calf - mild.D-dimer (+) -- not just borderline, but --> 3.74 (0.00-0.50 ug/mL)

No SOB or Chest pain, normal O2 Sat. U/S of leg is normal -- no DVT.My plan was to have her see Rheum - but not easily accessible in our region - to confirm possible Rheum Arthritis.She is lining up an appointment.

But I'm wondering what to do with the very high D-dimer -- suggesting lots of clotting somewhere.Should I be looking for an occult cancer?She had a normal CXR in 4/2010.Normal CT Abd/Pelvis earlier this month for some nonspecific abdominal pain - actually, there was some question of an inflamed appendix, but she was feeling better later in the day, so we continued to monitor and it resolved.

To throw some herrings in the mix..she does have the following...Right Hydronephrosis 9/09 - CT Abd/Pelvis 9/09 showed Moderate right-sided hydroureteronephrosis with the etiology of the obstruction being ureteral compression by an enlarged uterus.; saw Gyn who felt uterus OK; U/S Renal 11/10 showed 1. Unchanged mild right greater than left-sided hydronephrosis of unknown etiology.; Discussed informally with Radiology 11/10 - no specific further xray testing would add to workup; discussed w/ urology 11/10 if asymptomatic and no RBC/WBC in urine or pain and not worsening on U/S - monitor for now To add some flavor to the above recipe -- she is the mother of an employee.Where would you go next?I feel like I'm missing something -- and possibly something significant with the sky high D-dimer and CCP.

Locke, MD