Clinical cases/Case 1

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Case presentation[edit | edit source]

The rash.

A 30-year old man comes to the accidents and emergencies department with a presenting complaint of rash on both lower legs. He first noticed the rash two days earlier, but it progressively got worse. The rash itself is not painful but he has felt waxing and waning pains in his knees and ankles. He has also felt some nausea and colicky abdominal pain without vomiting or a change in bowel motions or stool appearance. He has not felt any fever or chills and denies urinary or respiratory problems. There have been no recent illnesses, no weight changes or night sweats.

The man has type 1 diabetes for which he has been on insulin injections since childhood. He has not take any other prescription or over-the-counter drugs and has no known allergies. He's a non-smoker who admits to occasional use of alcohol. He doesn't know details about medical conditions in his family. The patient works as a teller in a bank, is married and lives in the city with his wife and baby daughter.

His vital signs are as follows: temperature 37.1 °C (98.8 °F), pulse 74 bpm, blood pressure 160/90 mmHg, respiratory rate 12/min.

On physical examination, there is a non-blanching rash predominantly on the legs but extending to the lower back. The lesions are dark red and slightly raised. The patient admits to pain on deep palpation in all four quadrants of the abdomen. Bowel sounds are normal and no masses or organomegaly can be felt. There is no redness or swelling of the joints of the lower extremities. The lungs are clear to auscultation and heart sounds are normal. Examination of the head, eyes, ears, nose and throat are normal. No enlarged lymph nodes are palpated. There are no signs of meningeal irritation. A digital rectal examination shows a streak of blood on the finger. Further physical examination is unremarkable.

An electrocardiogram is found to be completely normal.

Laboratory tests are remarkable for leukocytosis (18,000 white blood cells /µl) and raised serum C-reactive protein (180 mg/L) and erythrocyte sedimentation rate (75 mm/h). There is also a raised creatinine (1.23 mg/dl,or 107 μmol/l) and glucose (138 g/l, or 7.7 mmol/L). The platelet count is 450,000/µl. Clotting tests are within normal limits. Liver enzymes, thyroid function tests, lactate dehydrogenase and creatine phosphokinase are within normal limits.

Your diagnosis[edit | edit source]

  • Question: What is the differential diagnosis?

1 What tests might be useful in this case?

Chest X-ray
Creatinine clearance
Serum protein electrophoresis
Rheumatoid factor (RF)
Antinuclear antibodies (ANA) and antineutrophil cytoplasmic antibodies (ANCA)
Serum complement levels
Anti-streptolysin O titers
Hepatitis serology
Anti-glomerular basement membrane (GBM) antibodies
Microscopic examination and immunofluorescence of a skin lesion
Abdominal ultrasound
Coronary catheterisation
Electromyography (EMG)

2 What is the single most likely complication in this patient?

Joint deformity
Bowel perforation
Renal failure

Case discussion[edit | edit source]