An asymmetric, oligoarticular, seronegative, inflammatory arthritis

[Guest guest]

American Academy of Family Physicians

Practice Diary

Chapter 50

November - December 2003

Sanford J. Brown, MD

An asymmetric, oligoarticular, seronegative, inflammatory arthritis

It's said that doctors' children never have easy-to-diagnose diseases,

and now I know why. Over a year ago, my teenage daughter, Margot, first

complained of mild discomfort in her right ankle. She had had assorted

sports injuries throughout middle school and high school, but she had

suffered no traumatic events that would explain her slightly swollen and

tender joint. Obeying the second cardinal rule in medicine after " Do no

harm " (that is, " Do not doctor your own " ), I sent her to Vic, my

orthopedic friend, who diagnosed a mild sprain of questionable cause. He

prescribed an ankle lacer and limited activities.

Margot improved and then, two months later, had an atraumatic effusion

of her left knee. Vic called it an " overuse " injury and advised rest and

elevation. Things quieted down until fall, and then Margot's knee

started swelling again, for no good reason. She was also having some

mild pain in her left wrist and right elbow. This time I ran a panel,

including an RA, ANA and Lyme; everything looked fine.

Then, four months later, the effusion returned with a vengeance. We did

an MRI and repeated the panel, but this time I added an ESR, which was

53 mm/hr, and a CRP, which was 7 mg/dL. Margot's disease was beginning

to look less orthopedic and more rheumatologic, so I consulted Jack, a

rheumatologist in a nearby city. " Tap the knee, " he said. " You still

don't have a diagnosis other than synovitis. And while you're doing a

diagnostic tap, do a therapeutic one as well. Inject some steroids into

her joint. "

Vic agreed to do the procedure and took off 100 cc of clear fluid and

followed with 100 mg of corticosteroids. Margot's joint-fluid analysis

was notable for a white-blood-cell count of 6,850 cells/ccm, with 46

percent polymorphonuclear and 54 percent mononuclear cells, but it was

unremarkable for culture, protein or crystals. Five days later, her

joint effusion had reaccumulated. This was an inflammatory arthritis,

not a series of mechanical injuries, and I was becoming less and less

comfortable with running my daughter's medical work-up.

Fortunately, Neil, our visiting rheumatologist, was due in for his

bimonthly visit. He immediately put Margot and my wife, Sue, at ease by

explaining things to them in lay terms: " The technical name for what you

have is an asymmetric, oligoarticular, seronegative, inflammatory

arthritis. It's asymmetric because it involves different joints on

different sides of your body; it's oligoarticular because it involves

several joints; it's seronegative because all the blood tests we've done

so far haven't given us the cause of your problem; and it's an arthritis

because your joints hurt and some are warm and boggy besides. Now, we

doctors are a bit like detectives, always trying to narrow the list of

possible suspects. Right now, it looks like you don't have lupus,

rheumatoid arthritis or Lyme disease. We're going to try and find the

culprit, but sometimes we just can't. In the meantime, it's important

that we keep your swelling and discomfort to a minimum. "

Neil's history taking had disclosed something Margot hadn't mentioned

before: She had been having night sweats for several months as well as

intermittent lower abdominal pains and occasional diarrhea. She denied

any rashes, which might have implicated a psoriatic process. " You have

to go where the symptoms are, " said Neil. " Inflammatory bowel disease

can cause arthritis. Dan still comes up here to do GI, doesn't he? You

might run it by him. I would also get a human leukocyte antigen B27,

parvovirus B19 IgG and IgM, an angiotensin-converting enzyme, and a

chest X-ray to rule out sarcoid. These are all dark horses, but what

else have we got? "

A curbside with Dan raised the possibility of Crohn's disease or

ulcerative colitis, both of which made my heart beat faster. " There's no

way Margot will go for a colonoscopy, " I said. Truth be told, Margot had

to get psyched up for a simple blood draw. " Well, we could do an upper

GI with a small bowel follow-through, " Dan allowed. " That's the least

invasive procedure I can think of that might give us an answer. "

With some coaxing, Margot agreed to the procedure and a chest X-ray.

Both were normal. Following that, both Margot and my wife were adamant:

no more tests. Margot was improving on anti-inflammatories, and they

wanted to leave well enough alone.

Still, I wasn't altogether satisfied. A chronically swollen knee and

painful joints in an otherwise healthy 17-year-old had to have an

etiology, but my hands were tied - or were they?

A Friday morning hospital conference featured a visiting rheumatologist

talking about non-steroidal anti-inflammatory drugs. I arrived early,

introduced myself and said, " Do you mind if I run a case by you? "

" Not at all, " he said, collegially.

" It's my daughter, " I said. " She has an asymmetric, oligoarticular,

seronegative, inflammatory arthritis, and we still don't know why. "

" Fax me her reports, and I'll give you my opinion, " he said.

The thought of getting his input made me feel better, but I couldn't

help but wonder how many more rheumatologists I would have to go through

before I could accept a disease description for my daughter's diagnosis.

Send comments to fpmedit@....

Dr. Brown, a solo family physician living in Mendocino, Calif., is a

contributing editor to Family Practice Management. These excerpts from

his journal illustrate the many characters, stories and lessons family

practice has to offer. No real patient names have been used. Conflicts

of interest: none reported.

http://www.aafp.org/fpm/20031100/diary.html

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

This will probably be my diagnosis. I used to think I was symmetrical, but

since my L elbow has been affected since 1996 and my R elbow is still fine,

I can¹t say I¹m symmetrical anymore. The same goes with my shoulder

involvement, it is only in one. Early in my disease only my L knee and

ankle were involved. Many years later it involved my other knee and ankle.

Hopefully Enbrel will slow the progression and spare other joints.

a

> American Academy of Family Physicians

> Practice Diary

> Chapter 50

> November - December 2003

> Sanford J. Brown, MD

>

>

> An asymmetric, oligoarticular, seronegative, inflammatory arthritis

>

>

> It's said that doctors' children never have easy-to-diagnose diseases,

> and now I know why. Over a year ago, my teenage daughter, Margot, first

> complained of mild discomfort in her right ankle. She had had assorted

> sports injuries throughout middle school and high school, but she had

> suffered no traumatic events that would explain her slightly swollen and

> tender joint. Obeying the second cardinal rule in medicine after " Do no

> harm " (that is, " Do not doctor your own " ), I sent her to Vic, my

> orthopedic friend, who diagnosed a mild sprain of questionable cause. He

> prescribed an ankle lacer and limited activities.

>

> Margot improved and then, two months later, had an atraumatic effusion

> of her left knee. Vic called it an " overuse " injury and advised rest and

> elevation. Things quieted down until fall, and then Margot's knee

> started swelling again, for no good reason. She was also having some

> mild pain in her left wrist and right elbow. This time I ran a panel,

> including an RA, ANA and Lyme; everything looked fine.

>

> Then, four months later, the effusion returned with a vengeance. We did

> an MRI and repeated the panel, but this time I added an ESR, which was

> 53 mm/hr, and a CRP, which was 7 mg/dL. Margot's disease was beginning

> to look less orthopedic and more rheumatologic, so I consulted Jack, a

> rheumatologist in a nearby city. " Tap the knee, " he said. " You still

> don't have a diagnosis other than synovitis. And while you're doing a

> diagnostic tap, do a therapeutic one as well. Inject some steroids into

> her joint. "

>

> Vic agreed to do the procedure and took off 100 cc of clear fluid and

> followed with 100 mg of corticosteroids. Margot's joint-fluid analysis

> was notable for a white-blood-cell count of 6,850 cells/ccm, with 46

> percent polymorphonuclear and 54 percent mononuclear cells, but it was

> unremarkable for culture, protein or crystals. Five days later, her

> joint effusion had reaccumulated. This was an inflammatory arthritis,

> not a series of mechanical injuries, and I was becoming less and less

> comfortable with running my daughter's medical work-up.

>

> Fortunately, Neil, our visiting rheumatologist, was due in for his

> bimonthly visit. He immediately put Margot and my wife, Sue, at ease by

> explaining things to them in lay terms: " The technical name for what you

> have is an asymmetric, oligoarticular, seronegative, inflammatory

> arthritis. It's asymmetric because it involves different joints on

> different sides of your body; it's oligoarticular because it involves

> several joints; it's seronegative because all the blood tests we've done

> so far haven't given us the cause of your problem; and it's an arthritis

> because your joints hurt and some are warm and boggy besides. Now, we

> doctors are a bit like detectives, always trying to narrow the list of

> possible suspects. Right now, it looks like you don't have lupus,

> rheumatoid arthritis or Lyme disease. We're going to try and find the

> culprit, but sometimes we just can't. In the meantime, it's important

> that we keep your swelling and discomfort to a minimum. "

>

> Neil's history taking had disclosed something Margot hadn't mentioned

> before: She had been having night sweats for several months as well as

> intermittent lower abdominal pains and occasional diarrhea. She denied

> any rashes, which might have implicated a psoriatic process. " You have

> to go where the symptoms are, " said Neil. " Inflammatory bowel disease

> can cause arthritis. Dan still comes up here to do GI, doesn't he? You

> might run it by him. I would also get a human leukocyte antigen B27,

> parvovirus B19 IgG and IgM, an angiotensin-converting enzyme, and a

> chest X-ray to rule out sarcoid. These are all dark horses, but what

> else have we got? "

>

> A curbside with Dan raised the possibility of Crohn's disease or

> ulcerative colitis, both of which made my heart beat faster. " There's no

> way Margot will go for a colonoscopy, " I said. Truth be told, Margot had

> to get psyched up for a simple blood draw. " Well, we could do an upper

> GI with a small bowel follow-through, " Dan allowed. " That's the least

> invasive procedure I can think of that might give us an answer. "

>

> With some coaxing, Margot agreed to the procedure and a chest X-ray.

> Both were normal. Following that, both Margot and my wife were adamant:

> no more tests. Margot was improving on anti-inflammatories, and they

> wanted to leave well enough alone.

>

> Still, I wasn't altogether satisfied. A chronically swollen knee and

> painful joints in an otherwise healthy 17-year-old had to have an

> etiology, but my hands were tied - or were they?

>

> A Friday morning hospital conference featured a visiting rheumatologist

> talking about non-steroidal anti-inflammatory drugs. I arrived early,

> introduced myself and said, " Do you mind if I run a case by you? "

>

> " Not at all, " he said, collegially.

>

> " It's my daughter, " I said. " She has an asymmetric, oligoarticular,

> seronegative, inflammatory arthritis, and we still don't know why. "

>

> " Fax me her reports, and I'll give you my opinion, " he said.

>

> The thought of getting his input made me feel better, but I couldn't

> help but wonder how many more rheumatologists I would have to go through

> before I could accept a disease description for my daughter's diagnosis.

>

> Send comments to fpmedit@....

>

> Dr. Brown, a solo family physician living in Mendocino, Calif., is a

> contributing editor to Family Practice Management. These excerpts from

> his journal illustrate the many characters, stories and lessons family

> practice has to offer. No real patient names have been used. Conflicts

> of interest: none reported.

>

> http://www.aafp.org/fpm/20031100/diary.html

>

>

>

>

> I'll tell you where to go!

>

> Mayo Clinic in Rochester

> http://www.mayoclinic.org/rochester

>

> s Hopkins Medicine

> http://www.hopkinsmedicine.org

>

>

>

>