A 57-Year-Old Male Retired Colonel with Acute Ankle Swelling

Military Medicine, Mar 2004 by McKinley, Brian T, Oglesby, Robert J

Walter Reed Army Medical Center

A 57-year-old male retired Army Colonel living in Virginia presented to Bethesda Naval Hospital for evaluation of a 4-day history of swelling and pain in both ankles. Swelling initially began in the left ankle and progressed to involve the right ankle and mid-foot region. Aggravating factors included dorsiflexion of the foot and weight bearing. His recent past medical history was significant for prostatitis that was diagnosed 2 months earlier. Other chronic medical problems included hypertension, benign prostatic hypertrophy, and gastroesophageal reflux. he was taking omeprazole, lisinopril, enteric coated aspirin, tamsulosin, and levofloxacin. The patient recalls a single episode of fevers and chills 1 day prior to the onset of the foot and ankle pain.

1. The most important diagnosis to initially rule out in this patient is:

a. Acute polyarticular gout

b. Reactive arthritis

c. Septic arthritis

d. Viral arthritis

e. Initial presentation of a systemic rheumatic disease (i.e., rheumatoid arthritis, systemic lupus erythematosus)

The goal of making an early diagnosis for any inflammatory arthritis is to institute the appropriate therapy so that joint damage can be minimized. Acute polyarticular gout involving the lower extremity can include the knees, ankles, heels, mid-foot region, and small joints of the toes. Even if untreated, however, most early attacks of gout would be expected to resolve in 7 to 10 days without significant joint damage. Reactive arthritis is typically associated with enteric or urogenital infections, is sterile, and can also cause inflammation along tendons or at the attachment of tendons or ligaments to bone. This may result in heel pain or plantar fascial pain depending upon its location. Early diagnosis of a septic arthritis, in comparison to the other options listed, is essential due to the potential for significant joint damage if left untreated. Polyarticular septic arthritis is relatively uncommon. In a report from one hospital, this diagnosis accounted for 16.6% of all septic arthritis with the majority (80%) caused by Staphylococcus aureus.1 Fifty-two percent had underlying rheumatoid arthritis and 36% had immunosuppression caused by drugs or concurrent illness. Viral arthritis, in comparison to bacterial arthritis, more typically occurs in a symmetric, small joint distribution and is nonerosive. An acute presentation of rheumatoid arthritis or other inflammatory connective tissue diseases would not be high on the differential diagnosis at this time due to the brief duration of symptoms.

On examination, the patient had a blood pressure of 128/74 mm Hg, a heart rate of 78 beats per minute, a respiratory rate of 14 breaths per minute, and a temperature of 99.0�F. He was well developed and well nourished and in no acute distress. He had male pattern hair loss and no evidence of facial rash or oral ulcers. Cardiopulmonary examination was normal. No lymphadenopathy was noted in the cervical, axillary, or inguinal areas. He had moderate swelling of both ankles with limited visualization of both the medial and lateral malleoli, fullness of the Achilles tendons, and pitting edema of the foot which extended to just above the ankle. The ankle joint itself was tender to palpation bilaterally; however, the most significant tenderness occurred with palpation of the Achilles tendons. Both Achilles tendon regions were diffusely swollen and without nodularity. Subtalar and plantar flexion of the ankle was normal; however, the patient was unable to dorsiflex beyond a neutral position because of pain. Other joints, including the mid-foot, first metatarsal phalangeal joints, and toes were without warmth, erythema, or swelling.

2. Physical examination features associated with Achilles tendonitis include all qf the following EXCEPT:

a. A palpable calf bulge

b. Tenderness along the length of the Achilles tendon

c. Swelling or warmth of the posterior ankle

d. Pain with passive dorsiflexion of the foot

e. Pain localized to the heel or back of the leg

A thorough physical examination of the involved joints and periarticular areas is essential in coming to the appropriate diagnosis. Careful evaluation of the Achilles tendon may reveal some nodularity; however, a calf bulge would not be expected in uncomplicated tendonitis. This finding would indicate some degree of tendonous rupture. Achilles tendonitis is associated with pain along the length of the tendon, most commonly several centimeters proximal to the calcaneus.

Because of the associated inflammation, the area may appear swollen and warm with fullness noted in the ankle region posteriorly. Pain would be expected to occur with active and passive dorsiflexion of the foot due to tension on the tendon. In some cases, pain may be described in the heel or more proximally in the calf.2

The patient was admitted to the hospital for pain management and further work-up of his ankle swelling. Radiographs of both ankles showed diffuse soft tissue swelling without fracture or degenerative changes. Laboratories were significant for a white blood cell count of 12,500/mm^sup 3^ (4,000-11,000/mm^sup 3^) with 69% neutrophils (51-67%) and 14% lymphocytes (21-35%), normal serum chemistry, erythrocyte sedimentation rate of 50 mm/hour (0-15 mm/hour), C-reactive protein of 9.87 mg/dL (10.0800 mg/dL), negative anti-nuclear antibody, negative rheumatoid factor, uric acid of 4.1 mg/dL (3.3-8.4 mg/dL), and unremarkable urinalysis. Five milliliters of blood-tinged fluid was aspirated from the right ankle shortly after admission revealing no crystals and a negative Gram stain. An automated cell count showed 333 red blood cells/mm^sup 3^ and 75 white blood cells/mm^sup 3^ (56% neutrophils, 16% lymphocytes, 28% monocytes).