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?