Rheumatology 5 – Case Presentation
Anil Chopra
History
 41 year old man of African origin
 Presented in Africa in November 1997 at the age of 35 years
 Lethargy and hyperpigmentation of both cheeks.
 Alopecia
 Arthralgia and joint swelling of his wrists, small joints of the hands and ankles
 No significant past medical history and was a non-smoker
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March 1998: difficulty in breathing and a productive cough
Pleural effusion.
No pathogen was isolated and extensive cultures for tuberculosis were negative.
Clinical suspicion for TB high: given trial of anti-tuberculous drugs for a total of
ten weeks
Unresponsive to this therapy
Worsening shortness of breath precipitated another hospital admission
Chest radiograph- basal pulmonary fibrosis
Echocardiogram- pericardial effusion
Sputum for AFB consistently negative
HIV test negative
ESR 5mm in 1st hour (low)
o Normal ESR can be calculated as age/2 (M) or age+10/2 (F)
Rheumatoid factor –ve; no LE cells.
Diagnosis and Initial Treatment
• A diagnosis of systemic lupus erythematosus (SLE) was made.
• Treated with prednisolone, initiated at 60mg/day.
• Shortness of breath and arthralgia resolved; chest X-ray findings persisted.
• Discharged on prednisolone 15mg/day and later commenced on azathioprine
200mg/day with a reduction in prednisolone to 5mg/day.
• Referred to rheumatology in the United Kingdom.
History In UK
• Summer 1999:
– significant shortness of breath on exertion
– arthralgia
– Cushingoid
Investigations
 FBC normal
 ESR 54mm in 1st hour
 C-reactive protein (CRP) 28mg/l
 Normal biochemical profile
 Normal complement levels C3 and C4
 Polyclonal rise in gamma globulins
 Rheumatoid factor -ve
 Antinuclear antibody (ANA) 1:2560
 Positive:
o anti-Sm, nRNP, Ro and La
 Negative:
o anti-dsDNA
o antineutrophil cytoplasmic antibodies (ANCA)
o anticardiolipin antibodies.
 Radiographs
o demineralisation at the MCP joints and wrists
o no erosive changes.
 A high resolution CT scan of the chest
o small bilateral pleural effusions with basal fibrosis
Diagnosis and Treatment
• Results confirmed the diagnosis of SLE
• Prednisolone dose increased to 10mg daily
• Hydroxychloroquine 400mg daily added
• Azathioprine 200mg daily continued
• Calcichew D3 forte 1 tablet bd
Progress
» Seen in the UK on a yearly basis and in between was monitored in Africa
» SLE remained under reasonable control
» Developed type II diabetes mellitus, presumed to be steroid related
» Summer 2003: pain in lower legs from mid-shaft of tibia to toes, maximal in his
heels
» Some difficulty walking
» Osteoarthrits:
• tenderness and warmth in hind feet
• both feet showed mild generalised swelling.
• peripheral pulses normal
» T scores:
• hip -0.5
• lumbar spine -1.6 – osteopenia.
Diagnosis
Calcaneal osteonecrosis:
Characterised by death of the constituents of bone marrow
Peripheral neuropathy:
Death or damage to peripheral nerves resulting in loss of feeling in the legs.
Algodystrophy
This is a complex of symptoms and signs characterised by severe pain, swelling,
autonomic vasomotor dysfunction and impaired mobility in affected joint areas. A
radiographic picture of the affected joint area shows inconsistent demineralisation in a
patchy or diffuse distribution. It may occur following trauma