Nov-Dec 2003 Table of Contents

PRACTICE DIARY

Chapter 50



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Fam Pract Manag. 2003 Nov-Dec;10(10):53.

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.

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.

Send comments to fpmedit@aafp.org.

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