Rheum Case 1

A 55 year old Caucasian male presented to a neighbor island ED with lower extremity skin rash, swelling and severe arthritis following a sore throat.

History of Present Illness:  Pt had an itchy and sore throat for which he was treated with azithromycin.  He sought out new antibiotics after 5 days without relief.  Approximately ten days after the onset of the sore throat, he went to bed complaining of a "sore wrist."  Upon awakening the following morning, he felt severe pain in both wrists with progressive immobility of the left wrist.  His skin broke out with a rash later on in the day on his hands, wrists and ankles.  His legs started swelling and he had difficulty walking.

Denied red eyes or pain with urination.

Past medical history: significant for migratory arthritis, Crohn's disease, HLA-B27(+).  Patient has a long history of severe anaphylactic/eczemal allergic reactions as well.

 

Pertinent physical exam:

Skin exam revealed multiple, progressive, round tender "palpable purpuric" lesions on the hands and ankles.

4+ pitting edema was present in the lower extremities.

 

Diagnosis: enteropathic arthritis and erythema nodosum most likely secondary to a streptococcal infection of the throat with subsequent reaction *HLA-B27(+)

Differential:
Reiter's/Reactive arthritis triad: conjunctivitis, arthritis, urethritis (Can't see, can't pee, can't climb a tree)

Course: Dermatology, ID, and rheumatology consultations were made.  Pt was reluctant to start a course of steroids in the ED, given a past history of steroid-associated insomnia and psychosis.  After 5 days of worsening edema and tender arthritis, he agreed to a steroid burst of 40mg daily and tapering regimen with rheumatology to follow.

 

References

eMedicine: Erythema Nodosum

eMedicine: Enteropathy arthritides

Learning Radiology: An Approach to Arthritis