“Good. I’m glad you’re widening your differential diagnosis beyond classical rheumatology. Lung cancer can trigger a paraneoplastic syndrome with swollen joints and fevers. So a CXR would be No. 1 on Willy Sutton’s list.”
“Willy Sutton?” She raised an eyebrow.
“The famous bank robber,” I answered. “Someone asked him why he robbed banks, and Willie supposedly said, ‘That’s where the money is.’ Chest X-ray, good thought.”
“But if the CXR is clean,” the resident added, “I keep thinking this guy smells like HIV. He’s losing weight, no appetite, weak, sweats; lymph nodes are on the juicy side. I’d say HIV from the heroin or the blood transfusion or an old sexual partner.”
“An HIV test (which, frankly, hadn’t crossed my mind) is a great idea,” I agreed. “But let’s say his CXR is normal and his HIV test is negative, I’m going to add hepatitis C vasculitis and hemochromatosis to the list.”
“Of course!” The resident could barely contain herself, she was so excited. “That is so cool! To evaluate for hepatitis C vasculitis, we should pick up a viral load for hepatitis C and cryoglobulins, and hemochromatosis is a genetic iron overload disorder.” She looked up and to the right, as if she were channeling a textbook: “Iron is toxic to the liver and can cause inflammatory arthritis and injure the pancreas, leading to diabetes. Over time, it can affect the function of the pituitary gland in the brain and trigger profound fatigue, and impotence. Eventually, it’s fatal due to liver or heart failure. Mr. Woodle has to have hemochromatosis,” she declared.
A Week Later
Only he didn’t. At my follow-up visit with Leon a week later, I reviewed the normal CXR, normal iron studies, clean HIV test, a minimal hepatitis C viral load and negative cryoglobulins. His joint swelling had spread to the other hand, and he’d lost another 2 lbs. The poor guy could barely make a fist or wipe himself after toileting, so I began 15 mg of prednisone, telling him that between the positive rheumatoid factor and the symmetry of inflammation, his illness probably represented rheumatoid arthritis. He took the prescription, and when I called him a week later, he said that he was about 60% better. But the diagnosis didn’t sit well with me, like I was trying to cram the diagnosis of RA into a pair of shoes two sizes too small.
When I ran into the resident at hospital Grand Rounds several weeks later, she remembered the pig farmer. I reviewed his partial response to prednisone and my tentative diagnosis of rheumatoid arthritis.