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. 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). ER Nurse's report. 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.
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.
I would think calcium pyrophosphate arthropathy most likely. I would have chucked in some colchicine if there no contras.
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 ?
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.
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.
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).
He had the swelling biopsied. 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.
