Chapter 17 Acute joint pain

Case 17.1

Dale, a 43-year-old male, presents with a 3-week history of fatigue and an intermittent, low grade temperature which is accompanied by chills, diffuse myalgias, arthralgia, headaches and a rash. He noted that the rash started on his right inner thigh and was initially 2–2.5 cm and bright red with an even distribution. This lasted for about a week, expanded to about a 10 cm diameter, and ultimately faded with the red colour remaining only at the border. Dale takes no medications, and had no known drug allergies. His family history was non-contributory. He denies tobacco and illicit drug use, and states that he uses alcohol in moderation. Dale has no pets, had not recently changed detergents or purchased new clothing. Before the appearance of the rash he was on a corporate paintball event in the Hamptons. The rash was noticed 5 days after the paintball event and progressed over the 3 weeks, to the extent where he sought medical intervention.

Questions

1. The table below lists possible diagnoses for Dale’s clinical presentation. Place an ‘X’ in the box if that disorder can potentially present with the corresponding symptoms or signs in their acute stage.

Questions

2. Which do you believe is the most likely diagnosis? Why?

3. What is the causative organism of this disorder?

4. If this disorder goes undiagnosed or untreated, what are the possible sequelae?

Case 17.2

History

John is a 52-year-old male builder who presents with a painful and swollen left knee. It commenced yesterday for no apparent reason, and progressively worsened over an 8-hour period. Today the pain has eased a little. He denies any recent trauma to the knee or any previous similar episodes in his knee or any other joints, and has no significant past medical history. His medical practitioner recently sent him for blood tests to rule out diabetes and thyroid problems due to his recent weight gain, and the results of these tests were normal. He denies any fever, malaise, night sweats or any recent loss of weight or appetite, does not take any medications and denies using any illicit drug use. John drinks a couple of large glasses of whisky most nights at home and is a non-smoker. He has not travelled abroad in the past 12 months. He is happily married and enjoys walking his dogs in the New Forest (Hampshire, UK) at the weekends. He has not noticed any tick bites or unusual rashes. There is no known family history of arthridities.

Questions

1. Using only this information, list the possible cause of John’s painful swollen knee. Justify your answers.

2. Why was John asked whether:

a he used illicit drugs

b he had noticed any tick bites or unusual rashes?

3. What do you need to examine in this patient?

Physical examination

Vitals	•Pulse rate/min	65, regular
	•Respiratory rate/min	16
	•Blood pressure mm Hg	145/95
	•Height (cm)	173
	•Weight (kg)	95
	•BMI	32
	•Temperature (degrees C)	38
HEENT	Unremarkable
Chest	No cardiomegaly, no murmurs, chest clear
Abdomen	Soft, non-tender, no masses
Limbs	Examination of the left knee revealed erythema, tenderness, swelling, some heat but no palpable bony enlargement. Both active and passive range of motion (ROM) of the knee were painful and limited, but with no crepitus. No rash, puncture wound or abrasions were noted around the knee. No other joints seem to be involved, and there was no evidence of tophi

Questions

4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

5. Explain the significance of the following signs in light of the differential diagnosis:

a blood pressure 145/95 mm Hg

b BMI of 32

c absence of tophi.

6. John is referred to a medical practitioner. What investigations are required, and why?

Investigations

X-rays of the knees show nothing other than swelling within the left knee.

Questions

7. What is the most likely diagnosis, based on these results? Justify your answer.

8. Are any further investigations required?

9. What are the potential complications of septic arthritis?

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