Left wrist and forearm inflammation and pain NYD, ESR 15 (normal), CRP 149 (very high)

Discussion in 'General Discussion' started by Jason, Jun 3, 2015.

  1. Jason

    Jason Developer / Handyman Staff Member

    If had a tough case of severe inflammation and pain of a patient's Left wrist and Forearm.

    88 yo male, healthy for age.

    It was initially treated in the ER as Cellulitis => didn't respond.
    It responded very well to Prednisone 50mg. It was fine on 25mg Prednisone.
    When the prednisone stopped it returned in 3 days.
    Prednisone was restarted on June 1, 2015.
    labs.severe.left.wrist.and.forearm.swelling.NYD.jpg
    Features:
    - severe pain.
    - CRP 149
    - now has thrombocytopenia
    - inflammatory markers worsening despite WBC now normal.
    - dramatic response to prednisone (swelling, inflammation) pain seemed to linger quite a bit.

    I referred the patient to rheumatology.

    This patient has a past medical history of Giant Cell Arteritis / PMR (in 2005)(stable on Methotrexate 15mg /week rally since then).

    His xray from April 6th (when it all started).
    upload_2015-6-3_16-46-38.png

    ER Nurse's report.
    upload_2015-6-3_16-59-42.png
    The first time, I would concur that the swelling eventually reached his elbow.
    On this second swelling, it started in the hand/wrist and had only proceeded 1/2 to his elbow before the second round of prednisone.

    To top it all off his wife just fractured her hip, getting surgery tonight.

    He's going to see a rheumatologist in 2 weeks.

    Plans: Probably will do ...

    (1) Workup for CPPD (Pseudogout) - he could be having severe gout like attacks [CPPD]
    • Low magnesium levels in the blood (hypomagnesemia)
    • Some causes of excess calcium in the blood (hypercalcemia)
    • An overactive parathyroid gland (hyperparathyroidism)

    (2) Acute Calcific Tendinitis http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654957/
    - I kind of this it might be this !

    Labs: PTH, Vitamin D, Serum protein electrophoresis, calcium, magnesium, albumin, ferritin, Repeat ESR, CBC, CRP.

    -------------------------------------------------------
    Thinking about ....
    MRI wrist and forearm - obscure tumor ? (probably wont help)
    Bone scan ? (probably wont help)
    Ultrasound of wrist and forearm tendons ... inflammation ? (might do this).

    == Research ==

    Discordance between erythrocyte sedimentation rate and C-reactive protein measurements: clinical significance. http://www.ncbi.nlm.nih.gov/pubmed/18078625
    Rheum and Malignancy
    http://www.uptodate.com/contents/ma...MUSCULOSKELETAL MANIFESTATIONS&anchor=H16#H16

    Any suggestions Graham, this has been a tough one.
    Last edited: Jun 3, 2015
  2. Jason

    Jason Developer / Handyman Staff Member

    Saw him today.
    Apparently 1 day of Prednisone and his wrist/forearm swelling resolved.
    Today was Day 3 and it is much better.

    I setup a prednisone taper that should be slow enough to avoid problems.
    I wanted to go quicker to 25mg but the patient and daughter pleaded for a slower taper.

    Prednisone 50mg 1 tab daily x 1 week.
    Prednisone 40mg 1 tab daily x 1 week.
    Prednisone 30mg 1 tab daily x 2 week.
    Prednisone 25mg 1 tab daily x 2 week.
    Prednisone 20mg 1 tab daily x 2 week.
    Prednisone 15mg 1 tab daily x 2 week.
  3. Graham

    Graham Developer Staff Member

    I would think calcium pyrophosphate arthropathy most likely.
    I would have chucked in some colchicine if there no contras.
  4. Jason

    Jason Developer / Handyman Staff Member

    Well done !

    That's what it probably was.
    or that's what the rheum said.

    I am very surprised how severe it got.
    colchicine is helpful in CPPD ?
  5. Graham

    Graham Developer Staff Member

    sure, interferes with neutrophil migration. Not specific to gout. Mediterranean fever etc.
    Jason likes this.
  6. Jason

    Jason Developer / Handyman Staff Member

    To add some interest to this case ... it would appear the MTX + Prednisone has suppressed his immune system enough to reactivate his TB !

    His AFBs were negative in the hospital ... but the Public Health culture was positive a few weeks later.

    I haven't seen him since June.

    The unresolved question is .... does he have TB in his forearm !
    (probably not, but it adds to the drama).

    I did hear he's had a few courses of Levofloxacin ... and that might help as it is a second line treatment for TB.
  7. Graham

    Graham Developer Staff Member

    Hmm. Not good. Was his IGRA positive?
  8. Jason

    Jason Developer / Handyman Staff Member

    I think it is being ordered this week.
    From what I heard, the patient looks great.
    So it's hard to diagnose disseminated TB when the patient looks great.
    Not sure what to make of the current twist.
  9. Jason

    Jason Developer / Handyman Staff Member

    Pt going on quadruple therapy.

    Here's what Rheum said:

    CPPD.vs.Tuberculosis.jpg


    Interesting case.
    :)
  10. Jason

    Jason Developer / Handyman Staff Member

    I guess this should make you think infection.
    upload_2015-10-12_14-15-2.png
    (From the Lab above).

    :)
  11. Jason

    Jason Developer / Handyman Staff Member

    Despite being on Triple Therapy.
    His arm is swelling again.

    He is being sent to Infectious disease to look at odd cases of infection (non-TB).
  12. Graham

    Graham Developer Staff Member

    What did the culture from the wrist aspirate show?
  13. Jason

    Jason Developer / Handyman Staff Member

    He had the swelling biopsied.

    TB.biopsy.jpg

    I thought of this thread, because Public Health called.
    They wanted to know what I knew about the patient's situation.
    They are worried because the recent AFB sputum was positive for Acid Fast Bacilli (I dont have it) ... but the old one from October was negative.

    upload_2016-2-26_16-51-14.png
  14. Graham

    Graham Developer Staff Member

    I guess PCR wasn't done on the wrist biopsy?
  15. Jason

    Jason Developer / Handyman Staff Member

    Doesnt look like it.

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