Wednesday, July 30, 2008

Case 6

A 43 years old male presented to the clinic for a regular follow-up and to refill his medications.

7 months previously he had had arthritis affecting his left knee and right wrist, which responded well to treatment with non-steroidal anti-inflammatory drugs. During the past month his left ankle become swollen and painful and he had noticed breathlessness while he was shopping for an ankle bandage

He gave a history of polyuria, polydipsia, and itchy eyes for the past 4 months. He drinks s socially at weekends and smokes 20 cigarettes a day. His mother is hypertensive, and his brother has hypothyroidism

On physical examination, he was afebrile, blood pressure 132/84 mmHg, pulse 76 /minutes, and respiratory rate 14 /minute. There was conjuctival injection, on the right nostril there is erythmatous lesion with crusty margins. On lung auscultation there is inspiratory crackles in the lower base and mid zone of the right lung. Hepatomegaly, Left ankle was swollen and tender.

Laboratory studies showed

WBC 8 x 10⁹/l, neutrophils 57%,lymphocytes 39 %, eosinophils 4%, Hemoglobin 12 g/dL, Hematocrit 42%, Platelets 194 x 10⁹/l, Sedimentation rate 40 mm in first hour, Sodium 136meq/L
, Potassium 4.1meq/L, Chloride 98meq/L, Bicarbonate 16 meq/L, Blood urea nitrogen 9mg/dL, Serum Creatinine 1.1 mg/dL, plasma glucose 89 mg/dL

Joint fluid aspiration showed gram stain negative

Chest X-ray right hilar enlargement with right mid and lower zone shadowing

Sputum revealed negative cultures and negative stain for acid fast bacilli


1- What is the most likely clinical diagnosis?

2- What are the possible causes for his polyuria?

3-How would you confirm your diagnosis?


ramashesai said...

1) sarcoidosis
2) central diabetes insupidus
3) Biopsy showing noncaseating granulomas.

ramashesai said...

1) sarcoidosis
2) central diabetes insupidus
3) Biopsy to confirm non caseating granulomas.

prabodh said...

1.) Sarcoidosis
2.) Nephrogenic/central Diabetes Insipidus.
3.)Fibreoptic/trans bronchial l.node biopsy, serum Ace levels, skin lesion biopsy, PFT'S apart from other routiine lab work.

rama said...

causes for polyuria- hypercalcemia,
DI secondary to sarcoid granulomas in volving hypothalamus.
biopsy confirmatory

rama said...

causes for polyuria- hypercalcemia,
DI secondary to sarcoid granulomas in volving hypothalamus.
biopsy confirmatory

rajiv said...

Reiter syndrome.
Triad of Arthritis, Uti, and Conjunctivitis.
The classical presentation is that the first symptom experienced is a urinary symptom such as burning pain on urination (dysuria) or an increased need for or frequency) of urination (polyuria. Other urogenital problems may arise such as prostatitis in men, and cervicitis, salpingitis and/or vulvovaginitis in women.
MRI's are effective for diagnosis.
The urethra, cervix and throat may be swabbed in an attempt to culture the causative organisms. Cultures may be carried out on urine and stool samples. Synovial fluid from an affected knee may be aspirated to look at the fluid under the microscope and for culture. Also, a blood test for the gene HLA-B27 may be given to determine if the patient has the gene. About 75 percent of all patients with Reiter's Syndrome have the gene.

Anonymous said...

Sounds like sarcoidosis. Patient has skin lesions, eye involvement, hilar shadows, arthropathy. Polyuria could be due to nephrogenic diabetes insipidus secondary to hypercalcemia.

Ranjita said...

contd...To confirm the diagnosis of sarcoidosis, serum ACE levels could be measured. Hilar lymph node biopsy could be done to show the presence of non caseating granulomas. PFTs could be performed in this patient to assess his lung function.

Anonymous said...

1) Rheumatoid arthritis
2) Diabetes insipidus or hypokalemia
3) ANA, rheumatoid factor, ss A, ss B

Himanshu said...

Patient seems to be affected by multisystem disorder affecting the lungs , joints, liver with cutaneous manifestation. SARCOIDOSIS is one of the multi stystem disoreder which can expalain all these symptoms.

1)Recurrent Ankle joint involvement:arthropathy in 25% of sarcoidosis patient, especially ankle joint.acute manifestation in the form of joint effusion.

2)Lung : most common site,90%,Usually upper and middle zone may present with SOB

3)Polydipsia/Polyuria: could be due to associated hypercalcemia or CNS involvement(anterior hypothalamic disease ) causes central diabetese insipidus.

4)skin involvement: 20%, maculopapular rash is more common among various cutaneous manifestation.

himanshu said...

5)Itchy eyes could be due to SICCA, and later in acute phase pt may have developed anterior uveitis.
POlyuria : 1) Hypercalcemia 2) Anterior hypothalmic disease leading to diabetese insipidus

6)Hepatomegaly: Liver involvement is not common but always present with gastrointestinal sarcoidosis.

Diagnosis : there is no specific test; High clinical suspicion with supportive lab findings establish diagnosis
In this patient
Skin anergy
skin biopsy: non caseating granuloma


Synovial Biopsy : non caseating granuloma
Pt desaturates with exercise

ACE activity increased