Fever and joint pains are two common manifestations of a variety of underlying diseases. These diseases may range from simple viral infections to some very serious diseases like cancers.

The following post is about a 22 years old male patient with fever and joint pains. He was investigated and managed at our Hospital. Here I am going to present his case scenario. This will be followed by a discussion in the next post.


Case presentation of the patient with fever and joint pains

fever and joint pains

A 22 years old male, Resident of Chakwal, Labourer by profession in Dubai (works at a steel company), Unmarried and educated till class 10th, presented in our OPD with

  • Pain in multiple joints for 4 months
  • Fever for 2 months

He was alright 4 months back when he developed swelling and pain in multiple joints, involving both small and large joints. This was associated with restricted movements of the affected joints without significant early morning stiffness.

The patient took multiple medications including antibiotics, steroids, and analgesics without any benefit.

Two months back, the patient developed a low-grade intermittent fever with occasional spikes associated with a non- pruritic rash on the lower limbs. The fever was associated with a sore throat and occasional episodes of epistaxis.

The patient had a mild cough but there was no history of sputum production or hemoptysis. Over the past two months, he has become progressively short of breath and reported undocumented weight loss.

There is No history of photosensitivity, oral ulcers, flu, rhinorrhea, hematuria, or pain abdomen. Rest of the systemic inquiry was unremarkable.

The patient is unmarried and has no promiscuous behaviors. He does not smoke and is not addicted to any substance. He belongs to a poor socioeconomic status.


Examination of the patient:

He was Toxic looking with the following Vital signs

  • Pulse: 104/min
  • Blood Pressure: 145/85
  • Temperature: 100 F
  • Respiratory Rate: 26/min

He was moderately pale, anicteric with a maculopapular rash on the lower limbs. The oral cavity was normal and the sinuses were not tender.

He had Active synovitis of bilateral wrists, elbows, knees and ankle joints.

Chest examination revealed occasionally scattered crepitations with normal vesicular breathing

Examination of the Abdomen, cardiovascular system and the central nervous system was unremarkable.


Summary of findings of the patient with fever and joint pains

To summarize, He is A young male patient with 4 months history of inflammatory polyarthritis, fever, Rash, Weight loss, occasional episodes of epistaxis and moderate pallor with scattered crepitations on auscultation of the chest.


Investigations of the patient:

  • CP:
    • Hb: 4.8 gm/dl
    • MCV: 76
    • HCT: 16%
    • TLC: 18430/ ul
    • Neutrophils: 80%
    • Platelets: 572000/ul
    • ESR: 140 mm/hr
    • Retics: 1.3%
  • Peripheral film:
    • Neutrophilic leukocytosis
    • Severe anemia ( with RBC morphology showing anisocytosis, hypochromia, microcytosis. Rouleux formation seen)
  • LFTs: Normal
  • creatinine: 2.07 mg/dl
  • Urea: 67 mg/dl
  • Na: 139mEq/l
  • K: 5.1 mEq/l
  • Calcium: 7.3 (corrected 8.1) mg/dl
  • Uric acid: 5.6 mg/dl
  • PT/APTT: Normal
  • Urine R/E
    • 2+ proteins
    • 3+ blood
    • Numerous RBCs
    • 06-07 WBCs/HPF
    • Casts: Not seen
  • 24-hour urine for proteins: 3480 mg/24 hours
  • Hep B, C serology: negative
  • HIV rapid test negative
  • RA Factor +ve
  • ANA –ve
  • C3: 126 (90-180)
  • C4: 27 (10-40)
  • Ultrasound abdomen: Grade 1 bilateral renal parenchymal disease
  • HRCT Chest revealed bilateral lung nodules with cavitations
wegener's granulomatosis
Bilateral lung nodules on HRCT chest
wegener's granulomatosis
Evolving lung cavitations on HRCT chest
fever and joint pains
Lung cavitations on HRCT chest
  • Bone marrow Aspirate: Diamorphic blood film
  • Bone marrow Trephine: Chronic disorder/infection-related changes
  • Transthoracic Echocardiography: Normal
  • Skin biopsy: Perivascular lymphocytic inflammatory infiltrate.

Questions:

How should we proceed further to diagnose this patient?

question

Follow up of our patient …

Our patient was diagnosed as a case of Wegener’s Granulomatosis after he had a strongly positive C ANCA.

Rheumatology consult was sought and he was started on steroids and cyclophosphamide.

Discussion about Wegener’s granulomatosis will be posted soon.

 

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shahzad ahmad
shahzad ahmad
3 years ago

How about getting Bronch for BAL?

Sputum for AFB, Quantiferon test.

Futher serum tests like antiGBM antibody. Anti dsDNA .

ANCA, Blood cultures.

B12, Folate, Iron profile.

Maliha Bukhari
Maliha Bukhari
3 years ago

Differentials:
: Sarcoidosis
: Wegener granulomatosis
: TB

Workup:
ACE levels, BAL, ANCA levels, renal biopsy.