00:00
Alright, I think it's time
for our next case.
00:04
Now we've got a 37 year old
computer programmer
with no significant past medical history
who's presenting with joint pain.
00:12
She reports that her left knee began bothering
her about 10 days ago,
followed by her left ankle
a few days later.
00:19
Yesterday morning she woke to
new pain in her second
and third toes of her right foot and
the soul of her left foot.
00:26
The pain in her knee in
particular is severe.
00:29
This has never happened
to her before.
00:31
She said she's a nonsmoker.
Rare alcohol use.
00:34
She's monogamous with her husband
of the past 11 years.
00:37
Her aunt has psoriasis review systems
reveal some fatigue,
low grade fevers, mild
low back pain,
and she also recalls an
episode of diarrhea
and low grade fevers
for several days.
00:51
But that was about
three weeks ago.
00:54
Let's go through our key points
on this case thus far.
00:58
The time course definitely sounds
acute to sub-acute
with an increasing number of problems
over the past 10 days,
the pattern of joint involvement
with left sided symptoms
and right sided symptoms involving
different joints.
01:11
It's clearly asymmetric and we've got more than
one joint so it's oligoarticular
Evidence of joint inflammation,
a little bit tricky to say
until we do a physical exam so
we'll hold off on that one.
01:24
Then systemic involvement with the fatigue
and low grade fevers.
01:28
We can say that the answer
to this one is yes.
01:31
All right. Wow. That's a big list of possibilities
for most likely diagnosis.
01:37
We'll have to go through each
of them in turn.
01:39
Here's some physical exam and
laboratory data.
01:41
First up, she does have a low grade fever
to 37.9 degrees Celsius.
01:46
Heart rates, okay, blood
pressures, okay.
01:48
She looks utterly
worn out.
01:51
No q distress, no
lymphadenopathy.
01:53
She's Anicteric and you note a
one by one centimeter shallow,
painless ulcer in the left buccal
mucosa shown here.
02:03
This looks somewhat like an aphthous ulcer
which is associated
with a variety of autoimmune conditions and
in particular the spondyloarthrititides.
02:11
cardiopulmonary exam is benign
or abdomen is benign.
02:15
The musculoskeletal exam reveals a hot
infusion to the left knee
we can definitely say that we have an
acutely inflamed joint.
02:23
We also have warmth and swelling
to the left ankle
tenderness to palpation at the right second and
third metatarsophalangeal joints
and tenderness to palpation at the
medial calcaneal tubercle.
02:34
But there's a lot going on in terms
of the lower extremities.
02:38
Let's take a closer look at that
medial calcaneal tubercle.
02:41
What we see here in this image on
the right is the calcaneus
which is the largest bone there on the
bottom right of the image.
02:49
At the very bottom is where the
plantar fascia inserts.
02:52
You can even see a tiny little
calcaneal bone spur
they're coming off the
calcaneal tubercle.
02:58
Plantar fasciitis is a fairly
common disease
that we oftentimes see in primary care
with folks who are obese
and folks who have flat feet and
are so called pes planus.
03:08
But it's important to realize
that plantar fasciitis
is also associated with
the spondyloarthritides
particularly reactive arthritis
and physical exam
if you palpate seeing on the
image on the far right
there on the medial
calcaneal tubercle
the place circled in the
black circle there.
03:25
That is very suggestive
of plantar fasciitis.
03:28
Alright, going back to
our physical exam
looks like there's no evidence of any findings
on the skin or on the nails
and then reviewing our
laboratory data.
03:37
Very mild leukocytosis
mild anemia
the ESR and CRP are
both elevated.
03:43
Importantly, our rheumatoid factor and
A.N.A are both negative.
03:48
That's really going to help
us to exclude
rheumatoid arthritis and
exclude lupus.
03:52
Likewise, lyme serologies
are negative
which is going to steer us
away from Lyme disease.
03:57
It looks like we decided
to tap the knee
that was completely
appropriate.
04:01
Our synovial fluid analysis yields
14,000 nucleated cells
of note the gram stains negative and
there's no crystals.
04:09
Let's talk about what the implication is
of those 14,000 nucleated cells.
04:15
You're going to see this a couple times and
all these lectures on rheumatology.
04:19
Starting with the left you have
non inflammatory conditions
moving to rheumatologic, gout
and septic arthritis.
04:25
You can see that the range of white blood
cells for each category
gives you a hint as to what
might be going on.
04:31
Our patient has 14,000. So it
puts her squarely
in the middle of the
rheumatologic disease
grouping there between
two and 20,000.
04:40
Keep in mind that those numbers
are not hard and fast.
04:43
You can certainly see some conditions
deviate above or below the range.
04:47
That's, that's
shown here.
04:51
Now that information which of the following
is the most likely diagnosis.
04:56
First with psoriatic
arthritis,
we really would need to see some
evidence of psoriasis
as I said 80 to 90% of patients
with psoriatic arthritis
are going to have some
psoriasis first.
05:07
Moreover, such patients tend
to have disease of the DIPs,
rather than all this stuff going
on in the legs
so we can safely X
that one out.
05:14
Rheumatoid arthritis this is clearly a
Seronegative problem.
05:18
Of course, as I mentioned, there are
some instances where
rheumatoid arthritis is diagnosed despite a
negative rheumatoid factor.
05:25
But this patient's symptoms
are not chronic.
05:27
Moreover, they're not
symmetric
we're not again having any involvement of
the hands so R.A off the table.
05:34
Systemic lupus erythematosus would not
typically be characterized
by so much joint
problems
without any of the other skin manifestations
that go along with it.
05:42
But most importantly, a
negative ANA
essentially takes SLE
off the table.
05:47
Lyme disease we already know our
serologies are negative
so that one's gone and
now we'll come back
to reactive arthritis in a moment.
But septic joint.
05:56
We already saw what the Arthritis
and Tisa showed
it was only 14,000 White
blood cells
that'd be very a typical for septic joint,
but more importantly
you don't get septic joint in a half a dozen
joints all at the same time.
06:08
So that's off the
list as well
Process of elimination, it looks like
we've got reactive arthritis.