Winter 2021 (Volume 31, Number 4)
Second Chances
By Philip A. Baer, MDCM, FRCPC, FACR
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“Sometimes life gives you a second chance because just maybe the first time you weren’t ready.”
– Author unknown
Our oldest functioning computer came with a free
solitaire game called Freecell. I still play occasionally,
but now I never register a loss. When I reach
a dead end, I can reverse course, undo every card I played,
and try again. So why give up when I can try over and over?
Some games are frustratingly difficult to solve, but all can
be won.
In medicine, some specialties provide more second
chances than others. If you are a surgeon, you better get it
right the first time: operate on the correct side, make sure
all sponges and instruments are accounted for, and every
suture is tied properly. If something goes wrong, a second
surgery may correct matters, but no one will be happy.
The cognitive specialties are generally more forgiving.
Some days, I’m on top of my game, recognizing a key triad
of symptoms that point to a diagnosis, ordering just the
right test to confirm a diagnostic hunch, and picking out
the rare outliers from the many patients who have a more
straightforward diagnosis. Other days, I recognize that I
am tired or just not in the groove. Those days, more time is
required, and nothing comes easily. If it is not an emergency,
the best course may be to order appropriate tests, rebook
the patient down the road, and rethink the situation.
That strategy also provides time for matters to become
more obvious: the patient with severe temporal headache
and a high CRP develops a classic shingles rash in the V1
distribution, or the patient with apparent seronegative
polyarticular rheumatoid arthritis (RA) develops clear-cut
psoriasis.
A common second chance opportunity presents itself
when a patient is referred back, often years after the initial
consultation. I had a trio of those patients arrive in the
same week recently.
The first patient had been seen in 2005 with a history
of intermittent “sausage” and locking fingers, sometimes
treated with antibiotics. This was followed by intermittent
attacks of acute synovitis in the fingers, wrists, and knees,
lasting up to 2 weeks at a time. Oral NSAIDs1 were of limited
benefit. Exam showed no evidence of psoriasis, and
the only MSK2 finding was slight tenderness of a single
PIP3. Lab tests showed a high urate of 435, a negative RF4,
and an ANA5+ 1:80. My working diagnosis was possible
psoriatic arthritis. Palindromic rheumatism and gout appeared
less likely.
The patient moved away. Sixteen years later, the patient
was referred back with a 1-month history of swelling of the
left hand PIPs and MCPs6, decreased grip, and inability to
make a full fist. This resolved after taking a course of an
over-the-counter (OTC) NSAID. A dermatology appointment
was pending regarding a scaly, flaky, itchy rash on
the ears. In this case, the outcome was confirmation of the
previously suspected diagnosis of psoriatic arthritis. Testing
showed a normal CBC7, ESR8 12, CRP9 5.4, negative
RF and B27, and urate 366. X-ray of the hands was normal.
Dermatology consult confirmed psoriasis.
The second patient was first seen in 2019 at age 70
regarding possible gout. Within the prior year, he had
three acute episodes, all involving the right knee, with
two ER visits. There was no redness, but he noted mild
warmth, swelling, and pain on walking. Between episodes,
he noted trouble kneeling. Each episode had responded
to the standard ER acute arthritis prescription: Prednisone
50 mg to 0 over two weeks. Examination showed
mild hand osteoarthritis (OA). The right knee was cool
without an effusion or Baker's cyst, with tricompartmental
crepitus, and flexion 0-110 degrees with stress pain.
Gait was normal, but pain was noted in the right knee on
squatting.
X-ray of the right knee showed moderate OA, particularly
in the medial compartment, with meniscal chondrocalcinosis.
Lab work revealed normal CBC, eGFR10 50, and
urate currently 360 (previously no higher than 400).
With new onset of gout at age 70 being unusual, I
thought most likely he was having episodes of osteoarthritis
flares in the right knee, possibly related to CPPD/chondrocalcinosis.
I stopped his prednisone, provided handouts
about OA management, and injected the right knee
with steroid. No fluid could be aspirated.
The patient was referred again recently, with episodic
joint inflammation, involving the left wrist three times
and the left ankle once. Short courses of colchicine 0.6
mg b.i.d. for a week and prednisone 30 mg/day helped. He
had occasional pain at the right wrist and elbow, and both
shoulders were limited in motion with some pain.
CBC was normal, ESR 73, CRP 57, eGFR 41, urate 350,
RF negative, calcium 2.6, phosphate and other chemistries normal, and TSH11 5.6. With recurrent episodic arthritis
involving knee, wrist, ankle, elbow and shoulders, the
prior diagnosis of OA with possibly incidental chondrocalcinosis
pivoted to CPPD arthritis with OA manifestations.
X-rays of the hands, wrists, elbows and shoulders confirmed
chondrocalcinosis at the elbows and shoulders, with
OA changes in the hands, wrists, and shoulders.
Lastly, a 50-year-old woman was seen in early 2020
describing a
12-month history of diffuse joint and muscle
pain in the upper and lower extremities and low back, the
latter mechanical in nature by description. After prior
neck pain, she was told she had arthritis at C5-C6.
Exam was unrevealing. CBC, ESR and CRP were normal,
and RF and anti-CCP12 were negative. I did not think she
had an inflammatory arthritis.
The patient was referred back only five months later.
Now, I was told that a first cousin had recently been diagnosed
with ankylosing spondylitis, was B27+, and was
about to start an anti-TNF13 agent. New labs showed she
was also B27+, while ESR and CRP remained normal. She
continued to complain of sleep impairment and diffuse
musculoskeletal discomfort in the hands, knees, shoulders,
shoulder girdles, neck, upper and lower back, without inflammatory
spinal pain by description.
On exam, there was no psoriasis or eye inflammation.
No peripheral synovitis was present, nor any dactylitis, enthesitis
or tenosynovitis. The neck and spine showed full
normal range of motion. Gait was normal.
Imaging by the family doctor now included ultrasound
of both wrists, both knees and the left elbow, all of which
were normal. X-rays of both feet, ankles, knees, SI14 joints,
hips, hands, and wrists were normal.
My impression in this case was unchanged. Despite
being B27+ with a family history of ankylosing spondylitis
(AS), her symptoms were not those of seronegative
spondyloarthropathy. I felt she had myofascial pain. I provided
spinal posture and exercise advice sheets, a general
stretching routine, and pain management strategies.
Three second chances: one opinion confirmed, one
modified, one unchanged. Nothing major missed, which is
always reassuring. Or at least I don’t think so, but if any of
these patients turn up a third time, further review will be
in order.
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario
Glossary:
1. NSAIDs: non-steroidal anti-inflammatory drugs
2. MSK: musculoskeletal
3. PIP: proximal interphalangeal
4. RF: rheumatoid factor
5. ANA: anti-nuclear antibody
6. MCP: metacarpophalangeal
7. CBC: complete blood count
8. ESR: erythrocyte sedimentation rate
9. CRP: c-reactive protein
10. eGFR10: estimated glomerular filtration rate
11. TSH: thyroid stimulating hormone
12. anti-CCP: anti-cyclic citrullinated peptide
13. anti-TNF: anti-tumour necrosis factor
14. SI: sacroiliac
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