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
