Looking Beyond the Obvious

Abstract

A 41-year-old male, previously well and employed as a university lecturer, was referred by his family physician to a rheumatologist at an urban university teaching hospital medical clinic. The patient had a history of feeling unwell (general malaise), occasional symptoms of chills and night sweats (but no documented fever), joint pain of the large joints on his lower limbs, and a recent rash on his lower legs, all appearing gradually over the preceding 2–3 weeks. The significant findings noted by the rheumatologist were a short midsystolic murmur at the cardiac apes (grade II/VI), no actively swollen joints, and the presence of scattered discrete palpable purpuric (non-blanching) papules of the legs. A tentative diagnosis of vasculitis was made, and blood tests, urinalysis, chest radiograph, and skin biopsy were performed. Complete blood count revealed mild anemia (hemoglobin 110 g/L), leucocyte count of 7,500 cells/μL, platelet count of 130,000/μL and an erythrocyte sedimentation rate (ESR) of 98/h and normal creatinine, urinalysis, and liver enzymes. The chest radiograph was normal and hepatitis B antigen and hepatitis C antibody were negative. The anti-nuclear antibody (ANA) was 1:30 with a speckled pattern, but the double stranded DNA antibody was negative. The rheumatoid factor was 1:120 and the anti-neutrophil cytoplasmic autoantibodies (C and P ANCA) were negative. Skin biopsy was reported as showing typical changes of leukocytoclastic angiitis or necrotizing vasculitis. The patient had no symptoms of dry eyes, xerostomia, or Raynaud’s phenomenon, and cryoglobulins and anti-phospholipid antibodies were negative. In view of the patient’s constitutional symptoms, he was placed on Prednisone 60 mg daily for 2 weeks, and then tapered by 5 mg per week.