Case for discussion: April 2017

A 19-year-old male reported to the outpatient department with arthritis and fever of 3 months duration. The first joint affected was the right foot, with the subsequent involvement of the joints of right hand, right knee, and the left foot. He had swelling in the right hand, right knee and both the right and left feet. The patient had restricted movement in the right knee and foot, and early morning stiffness for a duration of five minutes for the past two months. The patient complained about the unilateral backache on the lower right side persisting for the past two-weeks. His physical examination revealed generalised weakness, dry mouth, dandruff, cough and watery eyes. The patient was on non-vegetarian diet and had decreased appetite. He had normal bladder frequency and micturition, and disturbed sleep.

The patient was afebrile on examination, and was moderately built and adequately nourished. He was on stimulide, ofloxacin and omeprazole for the same complaints. The joint examination of the patient revealed tenderness and swelling in the right PIPs and MCPs of the hand, tenderness and swelling of both right and left feet and right knee, and tenderness in the spine. The results of clinical and laboratory investigations done during the previous consultation in another center, and present consultation are provided in table 1 and table 2 respectively.

Table 1: Results of clinical and laboratory investigations done during the previous consultation in another center

Parameters evaluated

Result

Hemoglobin (gm/dL)

13.4

Total WBC count (cells/cumm)

7100

Neutrophils (%)

60

Lymphocytes (%)

39

Eosinophils (%)

1

Monocytes (%)

0

ESR (Westrgren's method) (mm/hour)

95

Platelet count (lakh/ cu.mm)

2.0

Urine routine

Normal

S.G.O.T [A.S.T] (IU)

0.7

Serum uric acid

4.6

Calcium

7.6

Blood urea

18

Anti-ds DNA

Negative

 

Table 2: Results of clinical and laboratory investigations done during the present consultation

Parameters evaluated

Results

First visit

Second visit

Hemoglobin (gm/dL)

9.2

8.5

Total WBC count (cells/cumm)

3870

6270

Neutrophils (%)

48.0

55.7

Basophils (%)

0.3

0.3

Lymphocytes (%)

 44.7

32.9

Eosinophils (%)

 0.8

4.1

Monocytes (%)

6.2

7.0

ESR (Westergren's method) (mm/hour)

90

103

Platelet count (lakh/ cu.mm)

4.34

5.22

S.G.O.T [A.S.T] (IU)

-

9

S.G.P.T [A.L.T] (IU)

-

7

Creatinine (Kinetic Jaffe) (mg/dL)

1.1

0.7

C-reactive protein (Quantitative immunoturbidimetric method)

38.92

72.9

 

Please proceed for discussing the case..