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| * neuroq11 |
| | #531415 |
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A 48-year-old man is evaluated for a 6-month history of intermittent fevers to 38.3 °C (101 °F) and a 9.1-kg (20-lb) weight loss over the past year. He has had several episodes of pain, warmth, and swelling in his wrists, knees, and ankles during the past year. He also has had persistent stiffness and mild swelling of the metacarpophalangeal joints of both hands. Two episodes of posterior uveitis several months ago were treated successfully with corticosteroids, and he has occasional transient diplopia. He takes acetaminophen and naproxen for his joint pain.
On physical examination, temperature is 37.9 °C (100.3 °F). He has left lateral gaze nystagmus, and there is no lymphadenopathy. His arms and legs are thin, multiple metacarpophalangeal joints are swollen but nontender, and he has temporal muscle wasting. The peripheral pulses are normal. Neurologic examination is otherwise unremarkable.
On laboratory studies, hemoglobin is 10.2 g/dL (102 g/L) and erythrocyte sedimentation rate is 70 mm/h. Radiograph of the hands is normal.
Which of the following is the most appropriate next step in this patient's management?
1 anti DNA antibody essay
2 sural nerve biopsy
3 temporal artery biopsy
4 small bowel biopsy
5 bone marrow biopsy |
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| * Re:neuroq11 |
| #2188888 |
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Giant cell arteritis with PMR......
Temporal muscle wasting with diplopia & ESR elevated......
ONly option that makes sense....
anti-dna ...mainly SLE
sural nerve mainly amyloidosis
small bowel biopsy -IBD
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| * Re:neuroq11 |
| #2188983 |
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posterior uveitis,nystagmus,pain warmth and swelling of multiple joints are not pointing towards 100 % diagnosis of GCA.
instead these findings like polyarthritis,swelling and painful joints and RADIOGRAPH NORMAL,posterior uveitis,diplopia and sometimes nystagmus can be associated with SLE.
if we think ab small bowel biopsy,there could have given some GIT symtoms,diarhea atleast...so as that to think ab IBD related polyarthritis or with other malabsorptive disorders like whipple's etc.
BM biopsy should have done to exclude myeloma,lymphomas or leuekemias,or anemias..but except than wt loss,and anemia there were not given any other associated sx and sufficient lab data to think ab any myelopriliferative disorders...
we can think ab doing a sural nerve biopsy in the setting of PAN plus Hep B,but again sx are not sufficient to think ab hepatitis(no nausea,vomiting,fatigue,liver tenderness) or PAN(no abd pain)etc..
but as mangz said above sural nerve biopsy is also ideal for amyloidosis,then it can also be possible to consider amyloidosis in the setting of autoimmune disease...
or is it sarcoidosis...pretty difficult to say,,so most likely can be 1....????difficult one . |
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| * Re:neuroq11 |
| #2189001 |
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you guys ,
his arms and legs are thin ,why so much muscle wasting ? could it be something else? |
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| * Re:neuroq11 |
| #2189676 |
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Whipple's disease is a chronic infection with multiorgan manifestations, including uveitis, diplopia, asymmetrical inflammatory arthritis, and weight loss.
Small-bowel biopsy is indicated for this patient. A history of recurrent posterior uveitis, nystagmus, diplopia, and asymmetrical inflammatory arthritis accompanied by weight loss suggests a diagnosis of Whipple's disease. This condition is a chronic infection with multiorgan manifestations, which mimics a primary systemic autoimmune disorder.
Central nervous system symptoms may be prominent in patients with Whipple's disease, and these patients commonly have a history of symptoms or findings associated with abnormal gaze and ocular movements. Ocular signs of Whipple's disease may be secondary to central nervous system findings or to direct ocular involvement and may include uveitis, supranuclear ophthalmoplegia, diffuse chorioretinitis, glaucoma, epiphora, superficial punctate keratitis, and/or bilateral pannus formation involving the anterior chamber angles and corneal periphery. Constitutional features are common. Any asymmetrical, chronic, often intermittent inflammatory arthritis is characteristic and often suggests a diagnosis of Whipple's disease once crystal arthropathy is excluded.
Findings of bacteria and positive polymerase chain reaction testing on small-bowel biopsy would definitively establish a diagnosis of Whipple's disease. Many patients with this condition do not have diarrhea (malabsorption), and symptoms of wasting may be more notable than gastrointestinal symptoms.
1. This patient's pattern of symptoms and clinical findings are not highly suggestive of systemic lupus erythematosus. An anti-DNA antibody assay would not be helpful in establishing a diagnosis, because these findings would not definitively establish a diagnosis of systemic lupus erythematosus even if results of this assay were positive.
Giant cell arteritis typically develops in elderly patients, whereas this patient is young. In addition, his pattern of inflammatory arthritis is not suggestive of giant cell arteritis. Therefore, temporal artery biopsy is not warranted.
Sural nerve biopsy is not indicated for patients without documented clinical or nerve conduction abnormalities when pursuing a diagnosis of polyarteritis nodosa. Sural nerve biopsy frequently is associated with postoperative local morbidity.
Bone marrow biopsy is not particularly useful in a patient with persistent fever, uveitis, and inflammatory arthritis unless there is more specific concern for disseminated mycobacterial infection or lymphoma. |
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