Case for discussion: May 2017

A 49-year-old male presented to the outpatient department with a 20-year history of arthritis involving both right and left elbows, shoulders, knees and ankles. The joint involvement was symmetric, additive and relapsing. The patient had no swelling. He was having intermittent fever, associated chills and rigors, and early morning stiffness lasting for 30 minutes. The pain aggravated with work and cold climate. The patient also had bilateral backache for the past 20 years, and limitation of movement in the neck and the mid back.

The examination of his joints showed tenderness and swelling in right and left elbows and shoulders, and tenderness and swelling in the ankle and knee of the left leg. The systemic examination of the patient revealed normal cardiovascular, respiratory, and central nervous systems and per abdomen. The family history revealed the occurrence of ankylosing spondylitis in brother. The patient was moderately built and nourished, and was on non-vegetarian diet. He had sound sleep and normal skin. The patient was on nebivolol 2.5 mg for the past two months for hypertension. The results of clinical and laboratory investigations performed are given in table 1.

Table 1:Results of clinical and lab investigations done during the current consultation

Parameters evaluated

Results

First visit

Second visit

Hemoglobin (gm/dL)

13.8

14.0

Total WBC count (cells/cumm)

11020

9070

Neutrophils (%)

67.6

65.4

Basophils (%)

0.4

0.7

Lymphocytes (%)

24.6

27.0

Eosinophils (%)

3.2

1.9

Monocytes (%)

4.2

5.0

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

21

09

Platelet count (lakh/ cu.mm)

2.60

3.06

RBC count (g/dL)

4.8

4.9

Random blood sugar (mg/dL)

78

-

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

26

-

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

46

-

Creatinine (Kinetic Jaffe) (mg/dL)

0.9

1.2

C-reactive protein (Quantative immunoturbidimetric method)

-

3.8

CRP-NEPH (mg/L)

6.31

-

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)

0.6

-

Direct bilirubin (Modified Jendrassik)

0.2

-

Indirect bilirubin

0.4

-

Gamma GT

46

-

Total protein (g/dL)

7.6

-

Serum albumin (g/dL)

4.3

-

Globulin (g/dL)

3.3

-

AG ratio

1.3

-

Colour

Pale yellow

-

Appearance

Clear

-

Leucocytes (/hpf)

2-3

-

RBCs

Absent

-

Epithelial cells (/hpf)

1-2

-

Casts

Absent

-

Crystals

Absent

-

Reaction

<=5.0

-

Specific gravity

1.020

-

Protein

Negative

-

Sugar

Negative

-

Ketone bodies

Negative

-

Urobilinogen

Normal

-

Bile pigment

Negative

-

NIT

Negative

-

MG

1.7

-

ATG

4.48

-

Anti-TPO (Anti Microsomal Antibodies) by CLIA

32.48

-

T3

0.92

-

Thyroxine total - T4 by CLIA

8.15

-

TSH

4.06

-

Hematocrit (PCV)

38.2

39.7

MCV

78.9

80.7

MCH

28.5

28.5

MCHC

36.1

35.3

RDW

12.9

11.9

PDW

11.30

9.40

MPV

9.80

9.00

P-LCR

23.60

15.60

Vitamin D

25.9

83.1

Calcium (Arsenazo III method)

8.98

9.19

PTH

181.40

79.00

Alkaline phosphatase (Kinetic) (IU/L)

102

69

Phosphorous

3.54

3.96

 

Please proceed for discussing the case..