Case Discussion: November, 2013

Mrs SBP, aged 58 yrs, presented to the clinic with difficulty in sitting or squatting and frequent episodes of swelling in both the knees. She was having a history of knee pain from past 7 years. From past 15 days, the occurrence of severe back ache was also noted.  Reduction in pain was observed while resting and after taking analgesics. However, it worsened on exertion. The condition was diagnosed as psoriasis by the dermatologist and she was advised to be on steroid- based creams and lotions. Though the patient had dry mouth, it was not interfering with eating or speaking.  She was allergic to sulfa group of drugs. She was recently diagnosed with hypertension and was on enalapril treatment. Her daughter has been undergoing treatment for rheumatoid arthritis. She has attained menopause and had four successful pregnancies. The patient had also undergone hysterectomy for excess of bleeding and no malignancy was reported.

Physical examination revealed the presence of scaly lesions over both the elbow areas and a few on scalp. The knees had minimal swelling and were tender. There was limitation in extreme flexion and extension of knees. Her vitals were normal. Systemic examination was not remarkable.  There was tenderness over greater trochanter and plantar fasciae. Results of clinical and lab investigations (Table 1) and X-ray of both the knees (Fig 1) are given below.

Table 1: Results of clinical and lab investigations

Date Jun-13
HEMOGLOBIN  10.3 
TOTAL WBC COUNT  7210 
NEUTROPHILS  56.3 
BASOPHILS  0.3 
LYMPHOCYTES  37.4 
EOSINOPHILS  2.1 
MONOCYTES  3.9 
ESR(Westergren's method)  25 
PLATELET COUNT  3.78 
RBC COUNT  4.8 
RANDOM BLOOD SUGAR  181 
S.G.O.T [A.S.T ]  36 
S.G.P.T [A.L.T ]  27 
CREATININE (Kinetic Jaffe)  0.8 
C-REACTIVE PROTEIN (QUANTATIVE IMMUNOTURBIDIMETRIC METHOD)  5.44 
ANA IMMUNO-FLUORESCENCE (1:40 dilution) NEGATIVE Cytoplasmic filamentous pattern(3+)
RHEUMATOID FACTOR ASSAY (QUANTITATIVE IMMUNOTURBIDIMETRY) 20.5 
HUMAN IMMUNO DEFICIENCY VIRUS 1and2 (RAPID) NON REACTIVE 
HEPATITIS B SURFACE ANTIGEN-HBsAG(RAPID)  NON REACTIVE 
HEPATITIS'C'VIRUS ANTIBODY (RAPID)  NON REACTIVE 
TOTAL BILIRUBIN (Modified Jendrassik)  0.5 
DIRECT BILIRUBIN (Modified Jendrassik)  0.2 
INDIRECT BILIRUBIN  0.3 
ALKALINE PHOSPHATASE (Kinetic)  122 
GAMMA GT  36 
TOTAL PROTEIN  7.3 
SERUM ALBUMIN  4.1 
GLOBULIN  3.2 
AG RATIO  1.3 
IGE  464.20 
Others   
COLOUR  Pale yellow 
APPEARANCE  Slightly turbid 
EPITHELIAL CELLS  Occasional/hpf 
CASTS  Absent 
CRYSTALS  Calcium oxalates crystals present 
HAEMATOCRIT(PCV)  33.2 
M.C.V  68.9 
MCH  21.4 
MCHC  31.0 
RDW  21.4 
REACTION  5.5 
SPECIFIC GRAVITY  >=1.030 
PROTEIN  Trace 
SUGAR  Negative 
KETONE BODIES  Negative 
URO BILINOGEN  Normal 
BILEPIGMENT  Negative 
NIT  Negative 
LEUCOCYTES  3-4/hpf 
RBCs  Absent 

 

Fig 1: X-ray of both the knees

 

 

Discussion of the case