I recently saw a middle aged man with a swelling at the base of his left middle finger. Just that. Nothing else. He didn't even have much pain. His GP had sent him to Rheumatology because he couldn't explain the symptoms.
He looked well. The left middle MCP was swollen. All other joints were normal. He had had lots of bloods in primary care, including FBC, U&Es, LFTs, ESR, CRP, Rheumatoid factor- all normal. A plain X-ray had revealed an odd looking cyst in the head of the 3rd metacarpal, but all else was normal.
There was no history of trauma.
Thoughts?
....possibly Ganglion...profession of the pt?
ReplyDeleteTnx...
Dr Das
Very good attempt, Shonkus. However, this was not a soft tissue swelling, but swelling of the joint itself. You may not see this in non-Caucasian populations, but among Caucasians, 10% are heterozygous for hereditary haemochromatosis, particularly for the mutation C282Y (cysteine replaced by tyrosine). Hereditary haemochromatosis presents typically in middle aged men with liver disease, often cirrhosis, type 2 diabetes mellitus, and arthritis, typically beginning with the index and middle finger MCPs.
ReplyDeleteRadiologically, cysts may be found in the metacarpal head along with joint space narrowing. This man had a serum ferritin of over 1300ug/l and a transferrin saturation of 94% when I checked it. He turned out to be homozygous for C282Y.
This is an example of multisystem disease presenting to the Rheumatology clinic. What was unusual was that he did not have deranged LFTs diabetes or hypogonadism and the only clue to diagnosis was the single swollen MCP.
I suppose no sign is ever trivial. Given a serum ferritin over 1000, he is at risk of liver damage and cirrhosis, although currently asymptopmatic, and will need therapeutic venesection. That swollen MCP probably saved his life.
...North European ancestory I learnt...2nd nd 3rd MCP commonly afflicted...arthritis a feature of Hemochromatosis...
DeleteAppreciate ur enunciation of the case...will go back to ur older posts too to dig out info...Tnx..
Shonkus
....Mithu,how good or bad is Aspartame....I am prescribing sizeably to lot many Diabetics...Long term use implications? also,its now very common here tht my Fever patients sometimes show both features of Typhoid & DF with Widal positive for at least O & H in 1:320 dilution nd degenerating platelet counts to as low as 10,000/cmm.This category pose considerable challenge to me....its a regular pattern now...ur thoughts...
DeleteHi Shonkus. Lots of adverse press about aspartame in years gone by, but it has been extensively tested in many countries and is considered safe by the UK Food Standards Agency, which is good enough for me.
ReplyDeleteDon't rely on a single Widal test for diagnosis of Typhoid. Positive in many subjects in endemic areas such as the subcontinent because of previous exposure, hence not reliable. Further, of little use in acute stage of illness, particularly first week, as may be negative despite active infection. Only paired tests showing 4-fold rise in titre would be reliable, but for obvious reasons, not particularly useful in management of acute infection. Would suggest blood cultures.
Dengue Fever would be likely diagnosis if platelet counts are that low.
...Tnx for prompt reversal...yes keeping this in mind often the mgmt frm my end is empirical for Typhoid...DF is taken as the first priority....but the food & water contamination & bad Hygiene in the Labor Qtrs is rampant here leading to strong suspicion ,however I rely on the clinical findings of Fever pattern ...often cases would report to me as late as a week du2 terrible logistics of arrival frm Islands....C W Rosset as early as late nineteenth century in his travelogue to Maldives talked of Deadly Maldives Fever,he had visited & stayed for some time frm Colombo whn HMS CEYLON had dropped him enroute for repairs to Bombay...I am interested to know wht could have been this fever...how to trace the epidemiological history of any Fever during early times...is there any link to any data base....these Robinson Crusoe Islands have bulk nd bulk of Fever cases....
DeleteMaldives fever would have almost certainly been Dengue Fever.
ReplyDeleteHere's the oldest recorded account. You are unlikely to find a hard copy though!
"Rush AB. An account of the bilious remitting fever, as it appeared in Philadelphia in the summer and autumn of the year 1780. In: Medical Inquiries and Observations, Richard & Hall, Philadelphia p.104".
....fine..will peruse the link as suggested...last three days its raining "patients" like cats & Dogs....will reply to the hypercalcemia Q shortly....Tnx..
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