By Michael Westerman, M.D. Postdoctoral Fellow, Division of Geriatric Medicine, JHU Faculty Sponsor: Joan Bathon, M.D. • • • • Left Knee Pain and Swelling: • • • • Patients Arthritis: • • • History of Present Illness The patient is a 34 year old nurse from Kuwait with a history of “seronegative rheumatoid arthritis” who presented to Hopkins Orthopaedics for evaluation of pain, warmth and swelling in the left knee which was status post total knee replacement in 1996. In turn, she was referred to rheumatology for a second opinion regarding the etiology and management of her arthritis. The patient was well until October 1992 when she developed sore throat, fever and coma. ![]() No records were available for review. Apparently spinal fluid analysis and culture were nondiagnostic and she was treated with a combination of antibiotics and steroids. Although her overall status markedly improved, she complained of severe pain and swelling in the left knee prior to discharge. Arthrocentesis reportedly showed inflammation but no crystals or infection. Her knee pain was treated transiently with a course of oral prednisone. She subsequently developed pain in her shoulders, elbows, hips, and ankles as well. In 1993, because of continued joint pain, she was evaluated by a rheumatologist in London who noted synovitis in both knees, elevated sed rate, negative rheumatoid factor and negative ANA, and diagnosed “seronegative rheumatoid arthritis”. Seronegative Arthropathies are a heterogeneous group of. Seronegative spondyloarthritis symptoms are present in up to 50% of. Rheumatoid arthritis. She was treated with azathioprine 100 mg, prednisone > 10 mg qd and folic acid. In 1994 azathioprine was discontinued for unclear reasons. She complained of bilateral hip pain and was found to have “bilateral pathological fractures and ischemic necrosis” for which she underwent bilateral hip arthroplasties by a “Western surgeon” with excellent resolution of her pain. In 1996, methotrexate was begun. Because of persistent knee pain and “degenerative joint disease”, she underwent left total knee arthroplasty by a Kuwaiti surgeon in 1996. However, her knee pain never improved after surgery, and the knee remained warm, swollen and tender. At the time of her presentation at Hopkins in August 1998, she denied ever having pain or swelling in the wrists, small joints of her hands or feet. She denied morning stiffness, subcutaneous nodules or sicca symptoms. She complained of chronic bilateral shoulder and left knee pain and limited range of motion of all three joints. However, systemically she felt well and attributed her sense of well being to the institution of methotrexate in 1996. She had been on steroids since 1992 and admitted to regulating the dose herself for several years, taking as much as 90 mg per day when she feels poorly, sometimes staying at this high dose for several months. She denied Raynauds phenomenon, history of pleurisy or pericarditis, psoriasis, back pain, uveitis or conjunctivitis, dysentery. Medications: Methotrexate 12.5 mg qweek Prednisone 10 mg qd Folic acid 5 mg qod NPH insulin 30 units SQ qd Past Medical History: 1. No allergies. Medical Illnesses: type II diabetes (steroid induced). ![]() Prior hospitalizations: -total left knee replacement -bilateral hip replacements Social History: The patient is a nurse in Kuwait. She is married with a nine-year-old child. She reported smoking two packs of cigarettes per day for many years, and having two alcoholic drinks each day. Family History: negative for rheumatoid arthritis, lupus or other connective tissue disease. Physical Examination The patient was thin and in no acute distress. BP 102/64, pulse 92 regular, weight 136 lbs, afebrile. Her general physical examination was entirely unremarkable. Her skin examination was also normal with no psoriasis, alopecia, vasculitis, subcutaneous nodules. Joint examination was remarkable for the following: Right shoulder limited abduction and external rotation with pain in all planes of motion. Elbows, wrists and small joints of the hands – entirely normal. Hips status post total joint replacements, with good range of motion bilaterally. Knees left knee was warm, swollen and tender to palpation. There was marked varus deformity of the left knee. Right knee was without swelling or warmth. Innotab games walmart. Ankles and feet entirely normal. Laboratory Studies Chemistries entirely normal. Total protein = 6.1; albumin = 3.5. CBC: WBC = 10,900 with 87% neutrophils. Hematocrit = 35.7%. Platelet count = 392,000. Erythrocyte sedimentation rate = 30 mm/hr. Antinuclear antibody negative. Rheumatoid factor negative. Lyme disease titer negative.
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