The Rheumatologist
COVID-19 News
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Ankylosing Spondylitis Resource Center
    • Gout Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Systemic Lupus Erythematosus Resource Center
      • Rheumatoid Arthritis Resource Center
      • Gout Resource Center
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / These 3 Tough Cases from the 2018 Thieves Market Underscore Need for Clinical Diligence

These 3 Tough Cases from the 2018 Thieves Market Underscore Need for Clinical Diligence

February 17, 2019 • By Thomas R. Collins

  • Tweet
  • Email
Print-Friendly Version / Save PDF
VasutinSergey / shutterstock.com

VasutinSergey / shutterstock.com

CHICAGO—In the Thieves Market session at the 2018 ACR/ARHP Annual Meeting, rheumatologists from around the country presented a slate of challenging cases that emphasized the importance of clinical persistence and attention to detail, and the need to consider diagnoses that might not be common or obvious. Three of them are summarized below. (Look for more information on these interesting cases in coming issues.)

You Might Also Like
  • Intriguing Patient Cases Presented at the ACR Annual Meeting Thieves Market
  • The ACR’s State-of-the-Art Clinical Symposium: Rheumatologists Weigh in on Tough-to-Treat Cases, Paget’s Disease, Imaging
  • The ACR’s State-of-the-Art Clinical Symposium: Rheumatic, Malignant Disease Mimics Call for Diligence from Rheumatologists
Explore This Issue
February 2019
Also By This Author
  • The ACR’s State-of-the-Art Clinical Symposium: Experts Discuss Jakinibs, Osteoarthritis, Membranous Lupus Nephritis

Case 1

Sonam Kiwalkar, MD, a fellow at Oregon Health & Science University, Portland, presented the case of a 30-year-old woman who arrived at University Hospital with headaches, a worsening skin rash, low-grade fevers and arthralgias that had persisted over the past three months or so. A few months before, she had fatigue and a rash, and was seen in an emergency department. She was referred to a dermatologist for a biopsy, but she did not follow up. About two weeks later, she was admitted to an outside hospital for fevers, headaches and confusion, and treated empirically for bacterial meningitis.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Four years previously, the woman was diagnosed with lepromatous leprosy, but was non-compliant with her medications. She had no history of rheumatic diseases. She had emigrated from Micronesia in 2004.

On physical exam, she had a low-grade fever, splenomegaly, diffuse non-pitting edema of her arms and legs, synovitis and extreme tenderness of her wrist, metacarpophalangeal and proximal interphalangeal joints. She had oval macules of 1–2 cm with a red border, and a new rash that was erythematous and warm, with very tender subcutaneous nodules on her legs.

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

She had a leukopenia, normocytic hypo­chromic anemia and thrombocytopenia; a high erythrocyte sedimentation rate and C-reactive protein; a spot urine protein to creatine ratio consistent with 2 gm proteinuria; positive anti-nuclear antibody, ribo­nucleoprotein particle, double-stranded DNA and SSA tests; and low C3 and C4.

She was diagnosed with erythema nodosum leprosum (ENL), an immune-mediated leprosy reaction.

This diagnosis, Dr. Kiwalkar said, was favored over lupus because the woman had pancytopenia with a bone marrow biopsy showing of Mycobacterium leprae and the characteristic skin rash of ENL, which showed splenomegaly and the classic pattern on an acid-fast bacilli stain that indicates the presence of bacilli that cause leprosy.

ad goes here:advert-3
ADVERTISEMENT
SCROLL TO CONTINUE

Because ENL is also an immune-driven disease, it is hard to say whether the nephritis, arthritis and serologies were from ENL, lupus or both. Applying Occam’s razor, ENL required less speculation, so the patient received the ENL diagnosis.

ENL, which requires a trigger, might have been sparked by the bacterial meningitis. “ENL can cause autoantibody formation that can mimic our autoimmune diseases,” Dr. Kiwalkar said.

The patient was started on high-dose corticosteroids with initial fast improve­ment, and cyclosporine was added as a second-line agent, with M. leprae treat­ment. After a few weeks, she was doing better overall, but her dsDNA and comple­ment had not normalized, Dr. Kiwalkar said. The patient was later lost to follow-up.

She said there was still some question about whether the patient might have also had lupus.

“As the case unfolds, I think it will be a combination of both,” she said. “There are some case reports of ENL triggered by an infection and presenting with a similar clinical picture, and there are some reports of leprosy triggering lupus. The entire case is quite mystifying and only time will tell.”

Pages: 1 2 3 | Single Page

Filed Under: Conditions, Meeting Reports, SLE (Lupus) Tagged With: 2018 ACR/ARHP Annual Meeting, Cancer, case report, Checkpoint Inhibitors, cyclosporine, Immunoglobin, leprosy, nifedipine, pregabalin, tacrolimusIssue: February 2019

You Might Also Like:
  • Intriguing Patient Cases Presented at the ACR Annual Meeting Thieves Market
  • The ACR’s State-of-the-Art Clinical Symposium: Rheumatologists Weigh in on Tough-to-Treat Cases, Paget’s Disease, Imaging
  • The ACR’s State-of-the-Art Clinical Symposium: Rheumatic, Malignant Disease Mimics Call for Diligence from Rheumatologists
  • Calcineurin Inhibitor Pain Syndrome: A Case Report & Literature Review

Meeting Abstracts

Browse and search abstracts from the ACR Convergence and ACR/ARP Annual Meetings going back to 2012.

Visit the Abstracts site »

Rheumatology Research Foundation

The Foundation is the largest private funding source for rheumatology research and training in the U.S.

Learn more »

Simple Tasks

Learn more about the ACR’s public awareness campaign and how you can get involved. Help increase visibility of rheumatic diseases and decrease the number of people left untreated.

Visit the Simple Tasks site »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2021 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.