Help - Diagnosis needed

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Hi, needing some help on a patient seen yesterday with edema, erythema, hypersensitivity of skin on pressure, pain (not joint) duration 4-6 weeks with edema / pain gradually reducing over this time. Initially first attack occured 2 weeks after trip to Athens and was diagnosed as having Ross River Fever. Unilateral ankle to digit involvement (subsequent bouts bilateral involvement with ankle to digit only involvement) Flares up after having cold / flu. Apparently blood tests taken over three weeks are negative to gout, urine tests also negative, X-rays NAD. Treatment to date has been. 5 day course of steroids which eased symptoms somewhat, ice temporarily improves symptoms as does rest, massage and US toward end of bout has helped.

Vascular supply WNL, mild discrimatory sense loss on both PMA's, R dorsum and ILA, diminished R knee reflex, L dorsiflexors weak, R dorsiflexers 'cogwheel action'

I am really stumped, so is the GP, any ideas? Helen

 

Is there any joint involvement at all (local and/or systemic)?
Any history of infection (esp mild systemic infection)?

 

Sometimes after an infection(flu) there can be plantar peeling as well.Ask the patient if this happened.Postinfection a dromic syndrome(hope I spelled it right) can occur.Order some blood test to check for WBC,ESR,et al.steriods can help,but make sure you do not do a long course of these.

 

reply 14/9/05

There is no joint involvement and on talking to the GP this morning, 2 years ago the CRP (inflammatory marker) was over 90, now 23 (normal <10), blood in urine (cause being investigated), and ESR was 30. It only occurs after mild systemic infection (ie. cold or flu), no peeling of skin after episode.

 

We could be dealing with an infectious process as the CRP was so high.Ask about STDs as well.Lyme disease can also be here.Check for any skin lesions(target lesions in lyme disease) Check ANA for lupus as well.

 

Dear Helen
There is a very mixed picture here. Unfortunately I do not understand the abbreviations used. They cause conflict between groups. Could you clarify these?

Firstly you are talking about a possible infective process and then at the end you are talking a cerebral process (weakness and cogwheel action.)

How old is the patient? do they smoke? Is there Ross River infection in Greece?

Finally there is no correlation between blood levels and joint levels of uric acid. You have to take a joint sample to diagnose gout.
Musmed, Pau Conneely

 

Helen: How are you making out with the case?Did you follow up? Again,try to run a CBC with diff and SLA/B27 to rule out inflammatory processes.

 

What about ganglion cyst or Rheumatoid Arthritis.
It is very hard to help without a picture

Good Luck

 

I think you have already answered your own query...

You said that she was diagnosed with Ross River Virus - I assume this was confirmed with serology, and she produced antibodies to RRV.

Working in Queensland, the home of RRV, I see this condition commonly. It is also known as Epidemic Polyarthritis. It is caused by arboviral infection transmitted by femal mosquitos. Often it will be confined just to feet, with articular, non-articular musculoskeletal pain, and often a neuropathic component. Oedema is a hallmark, and this reduces with time. Other viral infections (eg influenza) will cause a flare-up of these symptoms. The disease (ie the 'fever') course can run for 1-2 years.

Treatment is localised and supportive, paracetmol and anti-inflammatories, ice, rest. I have occasionally used orthotics for some who have had significant plantar fascia pain with this virus.

Hope this helps.

 

Thanks for the replies, I am currently following through with the GP, hope to find out something soon.