A 39-year-old lieutenant colonel stationed in Saudi Arabia with arthritis, fevers, and rash

Military Medicine, Jan 2002 by Gilliland, William R

Case Management Study

Walter Reed Army Medical Center

Introduction

A 39-year-old active duty Caucasian Lieutenant Colonel stationed in Saudi Arabia was seen at Walter Reed Army Medical Center for evaluation of back pain and arthritis. He initially noted the back pain after exercising in a gymnasium 3 1/2 weeks prior to evaluation. He sought medical attention, was diagnosed with low back strain, and was treated with ibuprofen and cyclobenzaprine. Although initially he noted improvement, the back pain persisted. Five days before evaluation, he developed pain and swelling in his right knee, bilateral ankles, and left elbow with associated fever, malaise, dyspnea, headache, and nonproductive cough. He denied shortness of breath, weakness, parasthesias, and the use of any other medications.

1. Regarding acute inflammatory arthritis in U.S. military personnel, which of the following is CORRECT.

a. Viral arthritis commonly presents as an acute polyarthritis.

b. Acute gout in military-aged males would be unusual.

c. Staphylococcus aureus commonly causes polyarticular disease in healthy active duty personnel.

d. Lyme disease is endemic to the Saudi Arabian peninsula.

e. Outbreaks of acute rheumatic fever in military recruits have not been reported since the early 1970s.

The differential diagnosis of inflammatory arthritis in military-aged individuals is extensive and broadly includes both infectious and inflammatory etiologies. Among infectious etiologies, viral illnesses commonly may present with an acute arthritis, especially polyarthritis (more than five joints). Common viruses causing acute polyarthritis include parvovirus, hepatitis B and C viruses, rubella, mumps, enterovirus, herpesvirus, adenovirus, and human immunodeficiency virus infection. Gout is a common cause of inflammatory etiology in males after they reach adolescence, that generally presenting as a monoarticular process. Females are typically not at risk for gout until they reach menopause, except in rare instances of purine metabolism enzymatic deficiencies or defects in the renal handling of uric acid. Lyme disease may present with acute polyarthritis (or monarthritis), but the causative organism has not been isolated from the Saudi Arabian peninsula. Neonates and the elderly, not otherwise healthy young or middle-aged adults are at the highest risk for staphylococcal joint infections. Although the incidence of acute rheumatic fever had been declining for decades, except for sporadic outbreaks in American school children, there have been recent reports of outbreaks of acute rheumatic fever in military recruits in California and Missouri.1

On examination, the patient had a blood pressure of 136/90 mm Hg, a heart rate of 140 bpm, and a temperature of 102 deg F. His respiratory rate was 22 breaths per minute. He was well developed and well nourished, but appeared to be ill. His examination was remarkable for dry mucous membranes, but no ulcers or adenopathy. Cardiac examination was remarkable only for tachycardia. His lungs were clear to auscultation and percussion. His neurological examination was normal; specifically, there were no meningeal signs. His most notable abnormalities were in his skin and joint examinations. He had marked synovitis and periarticular swelling in both ankles and tenderness in his left elbow. An erythematous, warm, tender, and confluent papulonodular rash extended from his ankles proximally to his lower leg (Fig. 1).

2. A broad differential diagnosis of papulonodular lesions associated with arthritis would include both inflamnatory and infectious etiologies. All of the following should be considered in this soldier EXCEPT:

a. Systemic lupus erythematosus

b. Inflammatory bowel disease

c. Sarcoidosis

d. Mycobacterial infections

e. Lyme disease

The diagnosis of rheumatic diseases is often based on pattern recognition. This soldier presents with a syndrome of arthritis, rash, and fever. Often the skin is the most accessible tissue to biopsy and ultimately may help to determine the diagnosis, or at least narrow the possibilities. Papulonodular lesions associated with arthritis occur in primary immune-mediated syndromes (systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, sarcoidosis, Behcet's syndrome, and numerous forms of vasculitis); infections (neisserial, rheumatic fever, syphilis, fungal, mycobacterial, numerous viruses, and subacute bacterial endocarditis); and miscellaneous conditions (diabetes mellitus, hyperlipidemia, gout, and thyroid disease). Lyme disease is frequently associated with a rash that may include macules, papules, erythema, urticaria, an evanescent rash, or a malar rash. Erythema migrans is the classic rash occurring with early localized Lyme disease, occurring within days to 1 month after the tick bite. The lesion may be uniformly red or have a more complex "bull's-eye" appearance due to central clearing. Nodular lesions would be very atypical for Lyme disease.

He was volume resuscitated and a work-up was started. Initial laboratory evaluation was as follows (normal values in parentheses): 11,100/mm3 white blood cell count, 76% polymorphonuclear neutrophils, 14% lymphocytes, 9% mononuclear cells (4,800-10,800/mm3), 14.6 g/ldL hemoglobin (14-18 g/dL), 309,000/mm3 platelets (130,000-400,OOO/MM3), 45 mm/ hour erythrocyte sedimentation rate (0-15 mm/hour), 17.29 mg/dL C-reactive protein (0.02-5.00 mg/dL). Initial radiographs of his ankles showed only soft tissue swelling and his chest radiograph was normal. During his inpatient stay, he continued to have daily fevers and headaches. His major complaint was constant pain associated with the erythematous lesions on his lower legs and ankles. His back pain resolved without any specific therapy. Dermatology was consulted and performed a biopsy of the erythematous lesions on his lower legs. Biopsy results revealed a septal panniculitis, consistent with erythema nodosum.