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Rheumatology case 2


Rheumatology case 2


حالة سريرية

الوصف الكامل Background
A 22-year-old woman living in Massachusetts is evaluated for a 4-day history of multiple “bug bites” and left ankle pain. Her symptoms initially presented with painful, nonpruritic welts on her legs and severe left ankle pain 4 days after mowing her lawn. She has been walking with a limp.

On physical examination, temperature is 38.2 °C (100.8 °F). The left ankle is slightly swollen. On musculoskeletal examination, passive motion of the left ankle elicits pain. Her skin lesions are shown and are tender to palpation.

On laboratory studies, complete blood count, serum chemistry studies, and urinalysis are normal. Arthrocentesis of the left ankle yields 1.5 mL of fluid (leukocyte count, 4,000/µL [4 × 109/L]; 45% neutrophils). Polarized light microscopy shows no crystals. Culture results are pending.

كتابة حرة وطرح موضوع النقاش!
Which of the following is the most appropriate next step in this patient's management?

A. Left ankle radiography
B. Chest radiography
C. Initiate therapy for disseminated gonorrhea
D. Initiate therapy for Lyme disease

المرجع

.

Fouad's picture
by
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C. Initiate therapy for disseminated gonorrhea

a.m.a's picture
a.m.a
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D. Initiate therapy for Lyme disease
???

SINA's picture
SINA
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مع أنه شكل الآفات ما بيشبه لايم، بس هاد يلي خطرلي

SINA's picture
SINA
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both of u....why?
Fouad's picture
Fouad
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اختر البنيات لانها بتعمل مشاكل بالانسجة الرخوة وبتعمل الم مفصلي اكتر من التهاب مفاصل

على كل رح غير رايي

بنعمل صورة شعاعية وبنشوف شو في مافي

a.m.a's picture
a.m.a
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the most common thing about gonnorrhea is that is cause tensosynovitis

The skin lesions are not pretty characteristics for Lyme disease.

Hot sauce's picture
Hot sauce
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أنا بصراحة اخترت a

drhanadi's picture
drhanadi
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Quote:
ختر البنيات لانها بتعمل مشاكل بالانسجة الرخوة وبتعمل الم مفصلي اكتر من التهاب مفاصل
Quote:
(leukocyte count, 4,000/µL
mbs2380's picture
mbs2380
بعد التخرج

Quote:
The skin lesions are not pretty characteristics for Lyme disease.

تمام، وأنا هيك شفت كمان.

بصراحة يعني القصة التالية لل bug bites هي يلي خلتني أختار، " مع أني مو متذكرة فترة الحضانة"

SINA's picture
SINA
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طيب ليش a??? بشوا عم تشكوا؟؟

Fouad's picture
Fouad
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-أستبعد أن تكون الاصابة ب gonorrhea لأن فحص السائل المفصلي لايشير الى اصابة انتانية
-داء لايم محتمل ولكن الاعراض والعلامات غير نموذجية
-بالنسبة للتصوير الشعاعي للمفصل فهو غير مفيد في بداية الاصابة
-بقي الاجابة b أو d
شو رأيكم يا جماعة؟؟

a.ahmad's picture
a.ahmad
السنة السادسة


لايم أربع أيام بعد العضة؟ ما بظن، لهيك لح استبعد الأخير.. بعدين الحالة رثوية مو خمجية Laughing out loud

إذا بدون الآفات يلي على الجلد، وبدون الحرارة 38.2 مباشرة لح اختار الخيار الأول.. بس هيك لح صير ما بعرف..

KMG's picture
KMG
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Quote:
-أستبعد أن تكون الاصابة ب gonorrhea لأن فحص السائل المفصلي لايشير الى اصابة انتاني

it is negative early in the disease

mbs2380's picture
mbs2380
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طيب نزل الجواب ولا في حدا عنده رأي آخر؟؟؟؟؟

Fouad's picture
Fouad
بعد التخرج

Quote:
Quote:
-أستبعد أن تكون الاصابة ب gonorrhea لأن فحص السائل المفصلي لايشير الى اصابة انتاني

it is negative early in the disease

he means the WBCs count Eye-wink Eye-wink

Fouad's picture
Fouad
بعد التخرج

Quote:
it is negative early in the disease

بس الاصابة صرلها 4 أيام وهاد وقت غير قليل بالنسبة للاصابة الانتانية لأنها خلال أسبوع بتسبب تآكل مفصلي اذا ماتعالجت

a.ahmad's picture
a.ahmad
السنة السادسة


Well, I don't know why I can't feel those spots like lyme defects, I can see them as erythema nodosa more, ok don't laugh at me, that's how I see them
But, looking at the age, the WBC count, it looks more like reactive arthritis, caused by gonorrhea infection somewhere else
The only problem that there's no choice fit with this

ola-s
بعد التخرج

This may help you in Dx
it is about the disseminated Gonnococcal infection

The most common manifestation
of DGI is a syndrome of fever, chills, rash, and articular
symptoms. Small numbers of papules that progress to hemorrhagic
pustules develop on the trunk and the extensor surfaces of the distal
extremities. Migratory arthritis and tenosynovitis of the knees, hands,
wrists, feet, and ankles are prominent. The cutaneous lesions and articular
findings are believed to be the consequence of an immune reaction
to circulating gonococci and immune-complex deposition in
tissues. Thus, cultures of synovial fluid are consistently negative, and
blood cultures are positive in 45% of patients. Synovial fluid may
be difficult to obtain from inflamed joints and usually contains only
10,000 to 20,000 leukocytes/L

Hot sauce's picture
Hot sauce
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Quote:
he means the WBCs count

I meant both of them,the culture and the wbcs.........

mbs2380's picture
mbs2380
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Quote:
Well, I don't know why I can't feel those spots like lyme defects, I can see them as erythema nodosa more, ok don't laugh at me, that's how I see them

no , i c them the same way, too

Quote:
The only problem that there's no choice fit with this

not a big problem at allVery Happy

SINA's picture
SINA
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Hold a second I may appear stupid by that
But I think it is a sarcoidosis and the skin lesions are E.nodosume
so let's do a CXR

Hot sauce's picture
Hot sauce
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amazing Ola....
(Correct Answer = B)

Chest radiography is indicated for this patient to evaluate for hilar adenopathy. This patient's skin lesions are characteristic of erythema nodosum. An acute presentation of erythema nodosum accompanied by arthritis or periarthritis of the ankle raises high clinical suspicion for acute sarcoidosis. These features, accompanied by fever and hilar adenopathy, strongly suggest the diagnosis of Löfgren's syndrome, which is a variant of sarcoidosis.

Lymphomas; fungal or streptococcal infections; inflammatory bowel disease; and some medications, including estrogen, may cause erythema nodosum. Lymphoma rarely causes acute erythema nodosum and concomitant arthritis. Lymphoma and inflammatory bowel disease are less likely in the absence of peripheral lymphadenopathy and gastrointestinal symptoms, respectively. Histoplasmosis may mimic this acute sarcoidosis presentation in endemic areas.

Radiography of the ankle would simply confirm findings already established during the history and physical examination. Erythema nodosum is not a feature of Lyme disease or disseminated gonorrhea. Therefore, treating these conditions would not be helpful.

This patient's prognosis is excellent. A relatively short course of nonsteroidal anti-inflammatory drugs or low-dose prednisone may be used to alleviate her symptoms, if needed.

Fouad's picture
Fouad
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as I know there are two stages of dissimenated gono infection:
the first one is systematic and it is characterized by general fatigue ,the culture in the blood is pos ,wherase it is neh in the article.....
the second stage when the culture is neg in the blood and pos in the involved article..........

mbs2380's picture
mbs2380
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متقلين العيار شبيبة.. أكرك عجم!

بس معليش.. صار لازم نحل حالات صعبة لنو صرلنا حالين كتير رثوية على حكيم..

وين الجواب فؤاد؟

KMG's picture
KMG
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ok what should we give the pts for the bug bites?
Hot sauce's picture
Hot sauce
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Quote:
وين الجواب فؤاد؟

الجواب فوق...

Fouad's picture
Fouad
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wow, thanx alot, interesting indeed

SINA's picture
SINA
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other than erythema nodosun ,what are the clues that suggests sarcoidosis????????

mbs2380's picture
mbs2380
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Quote:
ok what should we give the pts for the bug bites?

it depends on how long was the bugs on the skine:
less than 24 h.. no treatment
more than 24 h .... treat woth doxycycline

Fouad's picture
Fouad
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Quote:
other than erythema nodosun ,what are the clues that suggests sarcoidosis????????

the age and the symptoms and signs....

Fouad's picture
Fouad
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