Answer 4

To summarize things up:

A case of polyarthritis involving the back with fever .

It is worthy to mention that the patient was crippled by his complaints.

@ Letters from internal medicine residents:

-An Email from Dr.Magdi Nagiub and Dr.Abd El-Hamid Abd El-Razik :

"...Problem:

Bilharzial affected patient with splenectomy developing high grade fever with polyarthritis mainly big joints and low vertebrae.

Discussion:

The above mentioned symptoms (fever, polyarthritis) in a 58 years old male is suggesting of a collagen disease most probably :

 

A-(ankylosing spondylitis) because of :

1-male .2-Elevated ESR 3-negative ANA and AntiCCP. 4-Low back tenderness.              5- Systemic manifestation and peripheral arthritis.

 

B- extra-hepatic manifestation of hepatitis C .

 

-Rhd arthritis is excluded by negative ANA and Anti CCP.

-systemic lupus is excluded by (Male, –ve ANA ) normal CBC.

-TB and septic arthritis is excluded by polyarthritis .

-Gouty arthritis (mainly small joints)......" Letter ended.

(A very logic intuition but I have some notices regarding:

-Ankylosing spondylitis is included in the DD if the disease course is chronic and dating from an earlier age , however  it is not the situation here.

-Regarding extra-hepatic manifestations of HCV infection : why to think of it while the patient fit clearly into another disease for which treatment relieved his symptoms ,besides extra-hepatic manifestations of HCV infection can be used indiscriminately to explain many such patients, to the degree that many diseases can be easily missed ,and in future I will publish similar examples of misdiagnosed "extra-hepatic HCV infections " patients. 

-I agree with you regarding the other disease possibilities.

 

Finally I want to thank you for your logic thinking and for sharing on the site ,and I hope  you would keep up with the future cases as your answers and other's form an important part of the discussion about the cases as they are a typical representation of most doctors who may have encountered the case as you see in the cases , thank you Dr.Magdi and Dr. Abd El-Hamid ).

 

-Dr.Ali Abou Taleb amused me with another Email:

".....according to the history of case 4 ,the patient had bilharziasis and
HCV infection but attacks of fever with joint inflammation take me to
many D.D as:-F.O.E as chronic infection like T .B and brucellosis or

                      -collagenes as Rh arthritis or

                      -Malignancy

but normal labs of  patient put my thinking in struggle ......"

Thank you Dr. Ali but keep looking !!

 

The final judgment :

As you see this case of polyarthritis with fever involving the back ,of a three weeks duration is approached in a manner considering rheumatic diseases that can explain this pattern of symptoms and signs. So the proper disease category which has the same pattern is the "seronegative spondyloarthritides " which involve a disease that is the one of concern here which is "reactive arthritis" .

Although this was the first possibility for me I saved no effort to exclude diseases that may represent in the same manner especially in this age like malignancies involving the bone, even by investigations.

But one can argue that the patient had no history of a preceding GI or urinary tract infections as a strict criteria for reactive arthritis, so I reply that the patient may actually had them but not giving an accurate history or he may be one of the small fraction of reactive-arthritis patients who have no prior infections before the manifestations appear who are now called  "undifferentiated spondyloarthritis" and who will eventually evolve to typical reactive arthritis.

I initiated the treatment immediately besides ordering some other investigations to exclude other remote possibilities because of the patient's age as I mentioned. So I prescribed him symptomatic treatment for fever and only I.V. antibiotic as the treatment for reactive arthritis after which the patient had a dramatic relieve in arthritis represented in the relieve of pain and effusion and decrease of temperature. (The patient was given steroids indiscriminately without a definite diagnosis on an occasion but without any improvement).