Some time ago, I was referred a 21-year old Caucasian man who had had a red rash on his legs a couple of months ago. Over the same period, he had been to the Emergency Department twice with pain and redness in his right eye, diagnosed as acute uveitis. The GP wondered if he had vasculitis.
In his other history, he had lost a stone in weight (6.3 kg) in 6 months without really trying. Over the last 12 months, he had had recurrent pilonidal sinus related infections in his bottom, diagnosed and treated with antibiotics by his GP. There was no history of Raynaud's, oral or genital ulcers, sicca symptoms or psoriasis. There had been no joint pains. He did not smoke but drank lager at weekends.
His GP checked his blood and documented: Hb 10.8 g/dl, MCV 82, WBC 11, Neutrophils 9, ESR 120, CRP 85, urine 300 RBC (normally <45), no proteinuria, normal U&Es & LFTs. RF negative, ANA weak positive in a nucleolar pattern, ENA, dsDNA, ANCA negative.
Examination showed no rash or synovitis, normal systems and an apparently healthy looking man.
I made the diagnosis, but only after calling him at home to ask him a question I had omitted in clinic.
Thoughts?
Shonkus, a quick update on MRS. Case series published in the NEJM does not pain a benign disease. Out of 23 patients, 15 died- a 65% mortality. Although p to p transmission is not enough to cause pandemics, it does occur.
ReplyDeleteHowever, most had underlying disease, particularly diabetes and all were inpatients, so perhaps patients with co-morbidities such as diabetes and CKD ought to be more careful.
Incubation time was 5 days, serial interval 7.6 days.
Reassuringly, last years Haj did not result in an increase in the number of cases. so far, only 80 cases reported.
Returning to the above case, these were the discussions so far, which were unfortunately lost due to temporary switch to another template.
ReplyDeleteComments from participants are in separate paragraphs.
SD: Tnx for this interesting posting....the One man Medical Board which I Head now,tnx to ur untiring efforts, for which I am grateful, hv tried an attempt aft.due deliberations....at the Onset:1) ESR &CRP r markers of Inflammation. A v.high ESR usually has an obvious cause,such as a marked increase in Globulins tht can be due to a severe infection.Asking for blood cultures is routine in this scenario. On the flip side people with MM, Wald.MG, wherein tumors make large amt of Immunoglobulins,typically hv v high ESR,even if they dont hv inflammation. 2) Caucasians r more prone to PMR & 50% is in association with Temporal Arteritis.There will be high ESR,Anemia,Vasculitis due to white cells attacking the Jt.linings, history of High dosage of antibiotics usage but no Oral Ulcers.3) Low levels of ANA indicate activation of the Immune system,possibly due to, Infection,Malignancy,or Inflammatory disorders. Since ,in this particular case ENA,dsDNA,ANCA are negative ,I am not inclined to believe Auto Immune etiology of SLE,rather would buy the theory of Weak positive ANA also is found in Normal Healthy Individual,with increase in freq. with age,& with intercurrent illness. Therefore SLE stands ruled out. Anti dsDNA is specific for SLE. 4) Given his Uveitis history nd treatment nd past h/o of Antibiotic Ingestion for Recurrent Pilonidal Sinus,I am more inclined to think in terms of Interstitial Nephritis caused either by infection or in majority due to Analgesics nd Antibiotics as incriminating agents. Most common cause of TIN is allergic reaction to a drug, explained by the rash which pt had before in his LL. Wt.loss, Hematuria are the findings. The infective factors leading to Pyelonephritis. Non infectious case of Uveitis & TIN leading to mCRP an auto antigen,common to both the Uvea & Renal tubular Cells, may be involved in the pathogenesis. Inflammation in this case will be T lymphocyte driven,the Immune cells hv a paradoxical suppression of Cytokine production, & a decrease in peripheral immune response. Antibiotics r highly implicated in this scenario. Though predominantly in youngest age groups yet also seen in adults i.e TINU Syndrome......Tnx...
NQ: Comprehensive and useful thoughts. PMR/GCA however, are strictly disorders of over-50s.
I asked the young man in clinic if he had diarrhoea. He denied it. The day after I saw him, I went through his history again and one feature stood out like a sore thumb. Why should a non-hirsute young man barely out of his teens have recurrent pilonidal sinus related infections? Then it struck me that these were peri-anal abscesses which the GP had erroneously diagnosed as pilonidal sinus related infections.
From there it was easy to figure out that the red rash on his legs in fact had been erythema nodosum (EN), and that this chap with recurrent uveitis, EN and peri-anal abscesses had Crohn's disease.
I called him at home and sure enough, his bowel pattern had changed over the past year from 1-2 stools per day to 4-5, usually semi-solid or liquid in consistency, which he did not consider "diarrhoea".
I asked the GP to refer him to Gastroenterology, and colonoscopy and biopsy confirmed Crohn's.
This case taught me two less appreciated facts. Firstly, it made me realise that Crohn's started very young- at onset, a disease that afflicts adolescents or neo-adults. Secondly, unlike ulcerative colitis, there can be a lag period of several years before it is diagnosed, when the patient may not complain of diarrhoea but may have other features such as weight loss, fatigue due to anaemia, EN, uveitis, peri-anal abscesses or even constipation due to ileal stricture.