Case for Discussion: June 2017

A 48-year-old male presented to the outpatient department with a 3-months history of arthritis involving both the right and left hands, wrists, elbows, shoulders, hips, knees, ankles and feet. The joint involvement was additive and symmetrical. The patient had swelling in both the knees and difficulty in squatting. He had early morning stiffness for a duration of 30 minutes, for the past three months, involving the mid and lower back, neck and buttock. The pain radiated to the legs and arms, and aggravated in the morning and with movement. Other than joints, the patient experienced pain in the palm and the soles. 

The patient had generalised weakness, dry mouth, dry skin, and hair loss. The systemic examination of the patient revealed normal cardiovascular, respiratory, per abdomen and central nervous system. The patient had a history of hospitalization last year for throat pain. He was on non-vegetarian diet and had normal appetite, bladder frequency, and bowel movement and disturbed sleep. He had quit smoking for the past two years.

The patient was moderately built and nourished. He was afebrile on examination with normal blood pressure. The ocular examination of the patient revealed refractory error in the conjunctiva, iris and sclera of both the eyes. Tenderness was noted in both the wrists, knees, elbows, shoulders and ankles on joint examination. Table 1 provides the details of clinical and laboratory investigations performed on the patient during the current visit. The X-ray findings of pelvis and palms are provided in figure 1 and 2 respectively.

Table 1: Results of clinical and lab investigations

Parameters evaluated

 

Results

 

Hemoglobin (gm/dL)

13.0

Total WBC count (cells/cumm)

69.20

Neutrophils (%)

69.7

Basophils (%)

0.4

Lymphocytes (%)

21.4

Eosinophils (%)

0.3

Monocytes (%)

8.2

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

23

Platelet count (lakh/ cu.mm)

0.98

RBC count (g/dL)

4.4

Random blood sugar (mg/dL)

96

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

24

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

24

Creatinine (Kinetic Jaffe) (mg/dL)

0.7

CRP-NEPH (mg/L)

11.90

ANA Immunofluorescence (1:40 dilution)

Negative

HLA- B27

Negative

RF-Nephelometry

<20.0

Hepatitis b surface antigen (HBsAg) by CLIA (rapid)

Non- reactive

Hepatitis 'c' virus antibody (rapid)

Non- reactive

Total bilirubin (Modified Jendrassik)

0.8

Direct bilirubin (Modified Jendrassik)

0.3

Indirect bilirubin

0.5

Alkaline phosphatase (Kinetic) (IU/L)

58

Gamma GT

31

Total protein (g/dL)

7.0

Serum albumin (g/dL)

3.9

Globulin (g/dL)

3.0

AG ratio

1.3

Colour

Pale yellow

Appearance

Clear

Leucocytes (/hpf)

2-3

RBCs

Absent

Epithelial cells (/hpf)

2-3

Casts

Absent

Crystals

Absent

Bacteria

Absent

Yeasts

Absent

Hematocrit (PCV)

38.0

MCV

87.2

MCH

29.8

MCHC

34.2

RDW

12.5

PDW

8.60

MPV

9.30

P-LCR

20.20

Reaction

Acidic (6.0)

Specific gravity

1.025

Protein

Negative

Sugar

Negative

Ketone bodies

Negative

Urobilinogen

Normal

Bile pigment

Negative

NIT

Negative


Fig. 1: X-ray of pelvis

 

Fig. 2: X-ray of palms

 

Please proceed for discussing the case..