ASK THE EXPERTS - Symmetrical ankle swelling in a 76-year-old patient

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Ask the Experts about Endocrine/Metabolic Disorders

Symmetrical Ankle Swelling in a 76-Year-Old Patient

Question

Can rheumatoid arthritis present as a symmetrical arthritis involving only

the ankles? My patient is 76 years of age, and presented with acute pain and

swelling of both ankles. The patient did not have other symptoms or

contributory history. Exam was notable for moderate-to-severe tenosynovitis

of both ankles. Radiographs demonstrate soft tissue swelling of the ankles,

ESR 66, CRP 13, RF pending. No improvement occurred after treatment using 2

different nonsteroidal anti-inflammatory drugs (NSAIDs).

J. Torcson, MD

Response from Mark E. , MD

Professor, Department of Internal Medicine, Division of General Medicine,

Geriatrics and Palliative Care, University of Virginia Health System,

Charlottesville, Virginia

Rheumatoid arthritis can certainly affect the foot and ankle, but this

usually occurs late in the course of the illness.[1] The clinical situation

described in this question would be a very unusual presentation for

rheumatoid arthritis.

A much more likely possibility in a 76-year-old with symmetrical ankle

swelling is crystal-induced disease such as gout or calcium pyrophosphate

dihydrate (CPPD) crystal deposition. Tenosynovitis is frequently seen in the

setting of crystal-induced disease. CPPD crystal deposition increases with

age.[2]

Perhaps not the most likely possibility, but an important consideration to

rule out, is the coexistence of a large- or medium-vessel vasculitis such as

giant-cell arteritis[3,4] or Wegener's granulomatosis.[5] Hepatitis C

infection can also produce rheumatic features, including tenosynovitis, that

resemble rheumatoid arthritis.[6]

The patient's sex and race are not included. Although somewhat unusual,

sarcoidosis would have to be considered if the patient is a black woman.

Another less likely possibility is flexor hallucis longus dysfunction. This

condition is often overlooked and can present as lower-extremity pain and

swelling.[7]

Finally, medication side effects should be considered. Achilles tendonitis

and even rupture have been reported with use of fluoroquinolones,[8-10] oral

corticosteroids,[11] and statins.[12]

One approach would be to tap the ankle joint to look for crystals, and

obtain blood studies for CBC, liver function tests, and electrolytes. A

urinalysis may also be helpful.

Posted 12/30/2002

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References

1.. O'Brien TS, Hart TS, Gould JS. Extraosseous manifestations of

rheumatoid arthritis in the foot and ankle. Clin Orthop. 1997;340:26-33.

2.. Halverson PB, Derfus BA. Calcium crystal-induced inflammation. Curr

Opin Rheumatol. 2001;13:221-224.

3.. Salvarani C, Hunder GG. Musculoskeletal manifestations in a

population-based cohort of patients with giant cell arteritis. Arthritis

Rheum. 1999;42:1259-1266.

4.. Kontoyianni A, Maragou M, Alvanou E, Kappou I, Dantis P. Unilateral

distal extremity swelling with pitting oedema in giant cell arteritis. Clin

Rheumatol. 1999;18:82-84.

5.. RM. Progress in rheumatology: understanding autoimmune

disease. Geriatrics. 1996;51:44-47, 51.

6.. Lovy MR, Starkebaum G, Uberoi S. Hepatitis C infection presenting with

rheumatic manifestations: a mimic of rheumatoid arthritis. J Rheumatol.

1996;23:979-983.

7.. Schulhofer SD, Oloff LM. Flexor hallucis longus dysfunction: an

overview. Clin Podiatr Med Surg. 2002;19:411-418.

8.. van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HG, Stricker

BH. Fluoroquinolones and risk of Achilles tendon disorders: case-control

study. BMJ. 2002;324:1306-1307.

9.. van der Linden PD, van de Lei J, Nab HW, Knol A, Stricker BH. Achilles

tendinitis associated with fluoroquinolones. Br J Clin Pharmacol.

1999;48:433-437.

10.. McGarvey WC, Singh D, Trevino SG. Partial Achilles tendon ruptures

associated with fluoroquinolone antibiotics: a case report and literature

review. Foot Ankle Int. 1996;17:496-498.

11.. Hersh BL, Heath NS. Achilles tendon rupture as a result of oral

steroid therapy. J Am Podiatr Med Assoc. 2002;92:355-358.

12.. Chazerain P, Hayem G, Hamza S, Best C, Ziza JM. Four cases of

tendinopathy in patients on statin therapy. Joint Bone Spine.

2001;68:430-433.

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