A 65-year-old man develops the onset of severe knee pain over 24 hours. The knee is red, swollen, and tender. The patient does not have fever or systemic symptoms. He has a history of diabetes mellitus and cardiomyopathy. Definitive diagnosis is best made by which of the following?
Acute monoarticular arthritis in association with linear calcification of the cartilage of the knee (chondrocalcinosis) suggests the diagnosis of pseudogout, a form of calcium pyrophosphate dihydrate deposition disease (CPPDD). In its acute manifestation, the disease resembles gout. Positively birefringent crystals (looking blue when parallel to the axis of the red compensator on a polarizing microscope) can be demonstrated in joint fluid, although careful search is sometimes necessary. Serum uric acid and calcium levels are normal, as are rheumatoid factor and antinuclear antibodies. Pseudogout is about half as common as gout, but becomes more common after age 65. Calcium pyrophosphate dihydrate deposition disease is diagnosed in symptomatic patients by characteristic x-ray findings and crystals in synovial fluid. Pseudogout is treated with NSAIDs, colchicine, or steroids. Arthrocentesis and drainage with intraarticular steroid administration is also an effective treatment. Linear calcifications or chondrocalcinosis are often found in the joints of elderly patients who do not have symptomatic joint problems; such patients do not require treatment.
A 35-year-old woman complains of aching all over. She sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient?
The patient’s multiple tender points, associated sleep disturbance, and lack of joint or muscle findings, make fibromyalgia a likely diagnosis. Patients with fibromyalgia often report dropping things due to pain and weakness, but objective muscle weakness is not present on examination. The diagnosis hinges on the presence of multiple tender points in the absence of any other disease likely to cause musculoskeletal symptoms. CBC and ESR are characteristically normal. Cognitive behavioral therapy and graded aerobic exercise programs have been demonstrated to relieve symptoms. Tricyclic antidepressants may help restore sleep. Aspirin, other anti-inflammatory drugs (including corticosteroids), and DMARDs (such as methotrexate or hydroxychloroquine) are not helpful, nor are simple stretching/flexibility exercises. Of note, rheumatoid factor and antinuclear antibodies occur in a small number of normal individuals. They are more frequent in women and increase in frequency with age. It is not uncommon for an individual with fibromyalgia and an incidentally positive RF or ANA to be misdiagnosed as having collagen vascular disease. Therefore, it is necessary to be careful to separate subjective tenderness on examination from objective musculoskeletal findings and to assiduously search for other criteria before diagnosing RA, SLE, or other collagen vascular disease.
A 38-year-old man has pain and stiffness of his right knee. This began 2 weeks ago after he fell while skiing. On two occasions he had the sense that his knee was locked in a semiflexed position for a few seconds. He has noted a popping sensation when he bends his knee. On examination there is tenderness over the medial joint line of the knee. Marked flexion and extension of the knee are painful. The Lachman test (anterior displacement of the lower leg with the knee at 20° of flexion) and the anterior drawer test are negative. What is the most likely diagnosis?
This patient has a medial meniscus tear. This may occur after trauma, but sometimes occurs spontaneously. Patients complain of pain, stiffness, and a popping sensation. A sensation of locking is very characteristic. On examination patients frequently have tenderness at the joint line and pain on flexion and extension. Routine x-rays are usually negative and the diagnosis is made by MRI scanning. Osteoarthritis usually occurs in patients older than age 50 unless the patient is very obese. OA pain typically comes on gradually, and physical examination may reveal patellofemoral crepitance. An anterior cruciate tear usually results from a twisting injury. It is a common injury in female soccer and basketball players. Frequently a large effusion occurs acutely. Chondromalacia patella is a common problem in runners. The pain typically worsens when the patient walks down stairs. The physical examination demonstrates lateral displacement of the patella with knee extension. Pathology in the back and hip may be referred to the knee, but is not associated with physical examination abnormalities localized to the knee.
Over the last 6 weeks a 35-year-old nurse has developed progressive difficulty getting out of chairs and climbing stairs. She can no longer get in and out of the bathtub. She has no muscle pain and takes no regular medications. She does not use alcohol and does not smoke cigarettes. On examination she has a purplish rash that involves both eyelids. There is weakness of the proximal leg muscles. What is the best next diagnostic test?
) This woman has dermatomyositis, which typically affects patients aged 40 to 50 who present with progressive proximal myopathy and complain of difficulty arising from chairs, climbing stairs, and getting out of the bathtub. About half of patients with dermatomyositis have the classic heliotrope rash. Lung involvement is common, but cardiac involvement is rare. Almost all patients have an elevated CK. Patients may have the anemia of chronic disease, which is normocytic. The EMG is characteristically abnormal with muscle fibrillations, spontaneous discharges, and sharp waves. In a small percentage of patients, the EMG may be normal. Muscle biopsy is usually diagnostic. High-dose oral corticosteroids are the treatment of choice. Some patients require the addition of methotrexate or azathioprine. Only 25% of patients are cured and most will develop a chronic condition with significant morbidity. Vitamin B12 deficiency causes distal sensory findings (rather than this patient’s proximal motor findings) and would not account for the heliotrope rash. Imaging studies of the lumbar spine would not focus on the primary process, although MRI scanning of the thigh musculature can be a useful study. HLA B27 is diagnostically useful in the spondyloarthropathies such as ankylosing spondylitis; this patient has no back pain or morning stiffness to suggest this diagnosis.
A previously healthy and active 72-year-old woman presents to your office with a complaint of stiffness and pain in her neck and shoulders. The symptoms are much worse in the morning and improve throughout the day. The pain affects the soft tissues and does not appear localized to the shoulder or hip joints. She denies headache or jaw claudication. Physical examination is unrevealing; there is no inflammatory synovitis, muscle tenderness, or skin rash. Muscle strength is normal in the deltoid and iliopsoas muscle groups. She has normal range of motion of the shoulder and hip joints. Laboratory studies reveal an elevated erythrocyte sedimentation rate of 92 mm/h and a mild normocytic anemia. Which of the following is the best next step in management of this patient?
The patient has polymyalgia rheumatica. A relatively common disease of the elderly, PMR presents as morning stiffness and pain in the shoulders, neck, and hip girdle. Diagnosis is mainly clinical; improvement of symptoms throughout the day and an absence of joint findings on physical examination provide clues to the diagnosis. Most patients have a markedly elevated ESR. PMR overlaps with giant cell (temporal) arteritis, so it is worthwhile to ask about symptoms of headache or jaw claudication. In the absence of symptoms or signs of temporal arteritis, no additional testing is indicated, and the diagnosis is presumptively confirmed by prompt response to moderate dose steroids (10-20 mg prednisone per day). Caution must be taken in tapering the steroids as patients frequently relapse upon discontinuation of treatment. A graded exercise regimen (answer b) would be an appropriate treatment option for fibromyalgia, but fibromyalgia rarely begins at age 72 and does not cause elevation of the ESR. MRI of the upper torso may show inflammation of the bursa and shoulder joint synovium, but this patient does not have localized tenderness in these structures. Muscle biopsy (answer d) is indicated in polymyositis or inclusion body myositis, but this patient does not have muscle weakness. Temporal artery biopsy (answer e) should be performed in patients suspected of having giant cell arteritis. Our patient, however, denies symptoms consistent with arterial involvement. If the patient does not respond to treatment with modest dose steroids, stronger consideration should be given to “blind” temporal artery biopsy.
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