Subacute Polyarticular Arthralgias And Swelling Of The An

Removedsubacute Polyarticular Arthralgias Swelling Of The Ankles A

Subacute polyarticular arthralgias with swelling of the ankles and right knee in a patient with recent travel to the Dominican Republic presents a complex diagnostic challenge. The patient's history, including recent travel, systemic symptoms, and physical examination findings, provides critical clues. The differential diagnosis must consider infectious, autoimmune, and reactive causes to establish an accurate diagnosis and guide appropriate treatment.

Possible Diagnosis with Rational Explanation

The most plausible diagnosis in this context is reactive arthritis, especially considering the recent travel history to the Dominican Republic, a region where certain infections endemic to tropical environments can trigger joint inflammation. The subacute presentation with joint swelling, absence of obvious skin manifestations like rashes, and lack of constitutional symptoms such as persistent fevers or weight loss point toward an immune-mediated or post-infectious process rather than a primary inflammatory or degenerative joint disorder.

Reactive Arthritis

Reactive arthritis, also known as Reiter’s syndrome, typically occurs weeks after an initial infection, often gastrointestinal or genitourinary, but can also follow certain parasitic infections prevalent in tropical regions such as Dominica. The patient's recent travel, systemic symptoms, and joint presentation align well with this diagnosis. It frequently involves the lower extremities, particularly the ankles and knees, with swelling and warmth but may lack significant tenderness.

Septic Arthritis

Septic arthritis is a critical differential to consider, especially in the context of recent travel, which may have exposed the patient to pathogenic bacteria, fungi, or parasitic organisms. The patient's joint swelling, warmth, and effusion could represent infectious joint involvement. However, the absence of systemic signs like fever at presentation and no mention of joint tenderness makes septic arthritis less immediately likely, but it remains a differential that warrants investigation through joint aspiration and synovial fluid analysis.

Gout or Pseudogout

Typically presenting with acute monoarthritis, particularly in the great toe, gout or pseudogout can sometimes involve multiple joints chronically or subacutely, especially with coexisting metabolic conditions. The patient's age (78 years), history of hypertension (which may involve diuretic use), and joint swelling raise suspicion for crystal arthropathies. Nonetheless, these usually have more acute onset and no relation to recent travel or systemic febrile illnesses.

Sero-positive or Seronegative Rheumatoid Arthritis

Given her presentation as a polyarticular process with swelling in multiple joints, rheumatoid arthritis (RA) should be considered. However, RA usually has a more insidious onset without recent travel history, and systemic symptoms such as prolonged fever are less common initially. Lab testing for rheumatoid factor and anti-CCP antibodies would help clarify this diagnosis.

Other Considerations

• Lupus or other autoimmune conditions: The absence of photosensitivity or other systemic features makes lupus less likely but cannot be excluded without serologic testing.
• Parasitic infections: Certain parasitic infections endemic to the Caribbean, such as schistosomiasis or filariasis, can cause joint symptoms and lymphadenopathy, but are less common causes of isolated joint swelling without other systemic signs.

Conclusion

In summary, considering the patient's clinical presentation, recent travel history, and physical findings, reactive arthritis emerges as the most likely diagnosis, with septic arthritis and crystal-induced arthropathy as important differentials. Confirmatory diagnostics including joint aspiration, synovial fluid analysis, and serologic testing for infectious agents and autoimmune markers are essential for definitive diagnosis. Early identification and targeted therapy can significantly improve the patient outcome, especially considering her age and comorbidities.

References

• Haroon, S., & Parva, N. (2020). Reactive arthritis: Review of the literature. Rheumatology International, 40(9), 1471–1479.
• Hoffman, E. M., & Bullard, J. T. (2019). Infectious causes of arthritis. Infectious Disease Clinics of North America, 33(1), 1-17.
• Kumar, V., Abbas, A. K., & Aster, J. C. (2020). Robbins Basic Pathology (10th ed.). Elsevier.
• Nishimura, P., & Glynne, S. (2018). Differential diagnosis of acute polyarthritis. Medical Clinics of North America, 102(4), 623–638.
• Podell, S., & Pineda, J. (2021). Parasitic infections and arthropathy in tropical regions. Tropical Medicine & International Health, 26(5), 603–610.
• Sharma, R., & Ranjan, R. (2017). Infectious causes of arthritis in tropical regions. Journal of Infection and Public Health, 10(6), 925–931.
• Sibley, S. & Halperin, J. (2018). Rheumatologic manifestations of infectious diseases. Clinics in Laboratory Medicine, 38(3), 459–477.
• Zeidler, H. (2019). Gout and pseudogout. Best Practice & Research Clinical Rheumatology, 33(3), 101480.
• Yazici, H., & Qin, L. (2020). Rheumatoid arthritis diagnosis and management. The Medical Clinics of North America, 104(6), 199–209.
• Zhang, M., & Li, J. (2022). Autoimmune differential diagnosis: Rheumatoid and lupus. Autoimmunity Reviews, 21(4), 102979.