Subacute Polyarticular Arthralgias And Swelling Of The Ankle

Subacute Polyarticular Arthralgias Swelling Of the Ankles And Right

Subacute polyarticular arthralgias, characterized by pain and swelling in multiple joints over a period of approximately 1 to 3 months, often suggest various underlying rheumatologic, infectious, or systemic conditions. In this case, a 78-year-old woman with recent travel history to the Dominican Republic presents with bilateral ankle swelling, right knee swelling, and a past history of febrile illness. Her symptoms developed after travel, with an initial febrile episode that resolved but left lingering joint symptoms. Physical examination reveals warmth, swelling, and effusion without tenderness, indicating active joint pathology possibly due to inflammatory or infectious processes.

Possible Diagnosis with Rationale Explanation

The primary considerations in this patient include infectious arthritis, reactive or post-infectious arthritis, and autoimmune inflammatory conditions. Based on her travel history, clinical presentation, and physical findings, the following differential diagnoses are most relevant:

1. Infectious Arthritis (Septic Arthritis)

Infectious arthritis, particularly bacterial septic arthritis, should be strongly considered given her recent travel to the Dominican Republic, an endemic area for certain infections. Septic arthritis often presents with joint swelling, warmth, and effusion, sometimes with systemic symptoms such as fever. Although her joint examination shows no tenderness—more characteristic of reactive processes—the initial febrile illness with joint symptoms raises suspicion of an infectious origin, especially if the infection involved hematogenous spread. Pathogens common in tropical regions, such as Salmonella species or Staphylococcus aureus, may cause septic arthritis or bacteremia leading to joint involvement. Diagnostic aspiration and analysis of synovial fluid (including Gram stain, culture, and cell count) are critical to confirm or exclude this diagnosis.

2. Reactive Arthritis

Reactive arthritis is an autoimmune condition that develops following or concurrent with certain infections, notably gastrointestinal and genitourinary infections caused by organisms such as Shigella, Salmonella, Yersinia, or Chlamydia. Although her initial febrile illness might suggest an infection, the absence of diarrhea, urinary symptoms, or a known recent infectious diagnosis makes reactive arthritis plausible, especially considering her travel history. It commonly affects lower limb joints symmetrically or asymmetrically and can present with swelling, warmth, and limited range of motion without overt tenderness. The latency between infectious trigger and joint symptoms varies but typically occurs 1–4 weeks after the initial infection. Laboratory markers such as elevated ESR or CRP support an inflammatory process, and serologic testing can identify antecedent infections.

3. Post-Infectious or Viral Arthralgia

Viral infections endemic to the Caribbean or tropical regions, such as hepatitis B or C, HIV, parvovirus B19, or dengue virus, can cause transient polyarthralgias that persist even after resolution of the initial illness. Her recent febrile illness coupled with residual joint symptoms suggests a post-viral inflammatory process. These viral arthralgias are often symmetrical, tend to involve small and large joints, and may be associated with skin rashes or lymphadenopathy, which she denied. Serological testing for viral infections may help confirm this diagnosis, especially given her recent travel and systemic symptoms.

Other Considerations

Apart from the primary differentials, autoimmune diseases such as rheumatoid arthritis could also present with symmetrical polyarthritis involving multiple joints. However, the recent febrile illness and travel history make infectious or post-infectious causes more plausible in this context. Rheumatologic workup, including rheumatoid factor, anti-CCP antibodies, and ANA, would help evaluate this possibility.

Conclusion

Given her recent travel to the Dominican Republic, febrile illness, and subacute polyarthritis, the leading diagnosis should be an infectious or post-infectious process, with reactive arthritis and viral arthropathy as the most probable causes. Confirmatory synovial fluid analysis and laboratory testing for infectious agents are essential for definitive diagnosis. Early diagnosis and appropriate management are crucial to prevent joint destruction and systemic complications.

References

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