This is the Xray of the right knee of a 72 year old patient who was complaining  of sudden onset  of severe pain and swelling of the right knee pain associated with severe neck pains, headache, high fever  with symptoms of the central nervous system.The patient's cerebrospinal fluid was almost clear and showed no sign of viral infection.Patient was initially treated  with non steroidal anti-inflammatory drugs with less improvement and then he was given corticosteroids  and he improved his condition dramatically.


Identify this Xray?
What are the other important investigations that you would do in this patient?

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15 comments

  1. Tanya Says:
  2. Septic arthritis

     
  3. Anonymous Says:
  4. could you please explain?

     
  5. Anonymous Says:
  6. cus the steroides improved his condition dramatically.

     
  7. Tanya Says:
  8. we are talking about intra articular steroid therapy ?

     
  9. Anonymous Says:
  10. Dr
    chondrocalcinosis(gout)

     
  11. i givw up
    i cant find something connect
    the prodromal symptoms with the age and the CNS manfistation
    and the dramatic effect of the steroids :S

     
  12. Anonymous Says:
  13. Rheumatic diseases sometime strats monoarticular..although the age of the patient is inaprporiate ...but certainly we should check for ANA Rh factor...CRP tbc,sedimentaion rate..and as well do some investigations for infectoius diseases..however the given data is infussient to come to any conclusions for the case

     
  14. Anonymous Says:
  15. arash from iran

    it is very interesting case which can teach us important approaching point in medicine
    according to my professor s(dr amininian) idea : we should tailor a dress(diagnosis) which can cover all parts (symptoms) of patient, it means your diagnosis should explain all symptoms and sign of your patient

    if you approach solely to knee pain there will be broad list of differential diagnosis , all rheumatologic disease , but if you add his headache and fever , very small numbers of disease can explain his symptoms

    now review the case , which disease can cause knee arthritis , headache and fever

    i think just lyme disease
    septic arthritis can explain arthritis and fever but not headache except the patient has sepsis , in sepsis condition septic arthritis MAY cause headache

    so diagnosis is" lyme disease "or" septic arthritis with sepsis"

    lyme disease has 4 stage
    1-early localized : in this stage patient has erythema migrans
    2-early disseminated: neurologic and cardian finding
    3-late : neurologic and arhritis and cutaneous findings
    4-post lyme disease syndrom

    diagnosis can be made by ELISA and CDC criteria

    CSF is normal in patient with headache WITHOUT OBJECTIVE NEUROLOGIC FINDING

    CSF showed pleocytosis in patient WITH OBJECTIVE NEUROLOGIC FINDING such as facial palsy

    treatment includes doxycyclin , cefuroxime , amoxicillin , ceftriaxone , ...

    -----------------------
    in x ray there is chondrocalcinosis in favor of CPPD but i can not his headache with CPPD

    steroid responsiveness is also in favor of CPPD

     
  16. Anonymous Says:
  17. behnood(iran.australia)
    many thanks to Arash.
    I think tis is not a a good training case.some parts are just missing, It`s rather like a puzzle which needs to be solved like a miss marple`s case!!!
    Though seems difficult in this particular case I suppose we should approach cases systematically.the patient probably has arthritis(not just arthralgia)and symptoms of meningitis.
    A clear CSF with no other abnormality mentioned in CSF analysis, bears in my mind that there is Aseptic meningitis.Therefor, we face a case with arthritis+aseptic meningitis. adding to this the chondrocalcinosis on xray.

    But it is unwise if we think that this patient has not undergone knee joint aspiration!!!because monoarthritis(especially that of the knee) with fever means septic arthritis until proven otherwise. So why they have started NSAID?definitely nothing concerning has been found in synovial fluid otherwise we should have expected empirical AB treatment.CSF assessment fro crystals is also indicated in this scenario.Interestingly when the NSAIDS failed , steroid was administered. We all know that this is a common practice in treatment of crystal induced arthropathies(including CPPD)to try NSAIDs first and then going for steroids.

    can we see meningeal or generally CNS presentations in CPPD? yes we can .hypercalcemia on its own can cause aseptic meningitis and some CNS symptoms.However we should not forget Sarcoidosis as a cause of Fever, meningitis,CNS problems(neurosarcoidosis)and acute or chronic arthritis( there is a syndrome named lofenger or something that if I remember rightly can cause acute monoarthritis, and fever and isa part of various pesenations of sarcoidosis)

    Lyme disease and some other spirocketal infections can also be suggested and also the very well known Jaricsh-Herxheimer reaction which again can causea severe inflammatory response like sever myaligia,arthralgia and aseptic meningitis which also responds dramatically to steroids. The only problem is that the patient has not been mentioned to have been treated by any AB.

    A useful clue in dealing with complicated and mysterious cases, is to think about rare presentations of common conditions rather than common presentations of rare conditions.

     
  18. hi everybody
    ive been thinking of this case since today morning

    lets start with the impression:
    i thimk the impression is psoudogout

    thats because its start in any age.. the patient age is 72 so the other causes can go with that age other than psudogout is infection due to aging process of immune system of the ealderly

    the monoartheritis picture goes with psudogout because it usually start in large joint as the knee

    CNS manifestation: as we know psudogout is usually due to deposition of ca-phosphate i think whichs usually due to metabolic disease or hyperparathyoidism..in which the CNS manifestation can be part of it!!

    and its a dramitically respond to steroid as we all know!!

    the xray also show deposition of ca in the intraarticular space (on the sides of it)

    so i prefer to relate the case as monoartheritis due to psudogout due to hyperparthyroidism..

    investigation will be: rhuamatology screening to exclude the other causes
    joint asprition for further gram stain acid fast bacilli,microbiology for crystals
    and also MRI and CT will be more spicific than the plain X ray

     
  19. sharimi Says:
  20. is anybody thinking collagen vascular diseases here?especially considering the xray which doesnt seem to reveal much to me,as would a non erosive arthritis in systemic lupus for instance,plus the dramatic response to steroids....am just wondering.....

     
  21. Admin Says:
  22. Correct Answer for this case is Calcium Pyrophosphate Dihydrate(CPPD) deposition or Pseudogout.
    CPPD deposition in the knee joint causes chondrocalcinosis.
    In Pseudo gout, periodontoid calcification result in crowned dens Syndrome.That is why this patient had developed the features similar to the meningoencephalitis.

    Investigation -synovial fluid analysis of the knee joint reveals crystals and CT or MRI will show the priodondoid calcification.

     
  23. Anonymous Says:
  24. I have to say, every time I come to your blog there is another interesting post to read. I
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  25. John Says:
  26. This article regarding Knee pain,Neck pain,Headache and High Fever is very interesting and useful, the headache issue can affect your sexual activity, and this not only happen to older people as I used to believed, young people can also be affected so you may need to buy viagra to help yourself on those situations. Thanks for sharing and have a nice day.

     
  27. Anonymous Says:
  28. asdad

     

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