New Patient CC: Any ideas?

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New patient, 33 Y/O male in very good health referred by Primary Care after unsuccessful arthritic work-up.

One month ago, for no apparent reason, this patient had swelling in both ankles and his left knee. No redness; but pain, not severe but painful on motion. No history of previous flare ups or any arthritic history. No apparent or obvious initiating factors. He was checked for Lymes and RA screening. CBC and ESR normal.

Undr examination he is WD/WN with no obvious clinical pathology. His ankles and knee appear normal. His x-rays were normal except early DJD left ankle which he attributed to an old severe ankle sprain.

OK ====== this is the kicker. Two weeks prior to his flare up his wife had a similar attack to both hands and one elbow!

They are both healthy, no recent trips out of the country, lived in the same home for past two years. No children. 2 Cats, healthy. Have not been in or visited the hospital or anyone sick. No histroy of recent flu or cold symptoms, no bites. No change in diet.

Any ideas?

Thanks

Steve

 

This may be a long shot, but this is from the lecture notes I used to give students:

 

Hi Steve

another long shot might be sarcoidosis, I guess ESR would likely be elevated but not sure if normal ESR would rule this out.

Since lung lymphatics are usually involved chest X ray might be helpful.

Because the cells that make up granulomas secrete large amounts of ACE, the enzyme levels are often high in patients with sarcoidosis. ACE levels, however, are not always high in sarcoidosis patients, and increased ACE levels can also show up in other illnesses.

another nice task for superUS, you would be able to confidently check for joint effusion and synovitis with power doppler

cheers

Martin

 

Hi Craig & Mart.
Thanks for your postings.
Anything that might connect his wife's episode with his?
Steve

 

Steve this has probably already been considered but other than coincidence the only thing that comes to mind is STD reactive arthritis,

here's a cut and paste to explain possibility

urethritis develops 7 to 14 days after sexual contact (or occasionally dysentery); low-grade fever, conjunctivitis, and arthritis develop over the next few weeks.

Not all features may occur, so incomplete forms need to be considered. In men, the urethritis is less painful and productive of purulent discharge than acute gonococcal urethritis and may be associated with hemorrhagic cystitis or prostatitis.

In women, urethritis and cervicitis may be mild (with dysuria or slight vaginal discharge) or asymptomatic. Conjunctivitis is the most common eye lesion. It usually causes eye redness and grittiness, but keratitis and anterior uveitis can develop also, causing eye pain, photophobia, and tearing.



Reactive arthritis should be suspected in patients with acute, asymmetric arthritis affecting the large joints of the lower extremities or toes, particularly if there is tendinitis or a history of an antecedent diarrhea or dysuria.

Diagnosis is ultimately clinical and requires the typical peripheral arthritis with symptoms of GU or GI infection or one of the other extra-articular features. Because these may manifest at different times, definitive diagnosis may require several months. Serum and synovial fluid complement levels are high, but these findings are not usually diagnostic and need not be measured except to rule out other disorders.

let us know if you get definative Dx



Martin


The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hi Mart:

"STD reactive arthritis" - I did consider this at the time of his history and did asked about UT symptoms, STD, etc...... I also told him why I was asking. Of course I assume he is telling the truth with his negative responses.

I'm not a big believer in coincidences, but this "may" be one.

Thanks

Steve

 

Any handcuff/ligature marks ?

 

Parvovirus??

 

Gonorrhoea? or Reiters? Both give non specific arthritic type involvement with or without fever

 

tut tut .... we are not supposed to use that word anymore. Dr Reiter was Hitler's doc and involved in the Nazi experiments, so a conscious decision has been made by the rheumatological community to strip him of the honor of having a disease named after him.

From Gabe Mirkin's essay on THE DESPICABLE DR. HANS REITER.

 

Ok I will consider myself slapped on the wrist :bang:
Your answer though informative, does not tell me what we now call the associated set of symtoms that were previously described as ******

 

They now come uner the 'Reactive' group of arthridities :drinks

 

So the name has been withdrawn and the symptoms no longer exist as a coherent sub group?

 

Pretty much ...check this from eMedicine: