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Rheumatology 5 Case Presentation Anil Chopra History 41 year old man of African origin Presented in Africa in November 1 !

1 ! at the age of "5 years #ethargy and hyperpigmentation of both chee$s% Alopecia Arthralgia and &oint s'elling of his 'rists( small &oints of the hands and an$les No significant past medical history and 'as a non)smo$er *arch 1 +, difficulty in breathing and a productive cough Pleural effusion% No pathogen 'as isolated and e-tensive cultures for tuberculosis 'ere negative% Clinical suspicion for ./ high, given trial of anti)tuberculous drugs for a total of ten 'ee$s 0nresponsive to this therapy 1orsening shortness of breath precipitated another hospital admission Chest radiograph) basal pulmonary fibrosis 2chocardiogram) pericardial effusion 3putum for A4/ consistently negative H56 test negative 23R 5mm in 1st hour 7lo'8 o Normal 23R can be calculated as age9: 7*8 or age;1<9: 748 Rheumatoid factor ve= no #2 cells%

>iagnosis and 5nitial .reatment ? A diagnosis of systemic lupus erythematosus 73#28 'as made% ? .reated 'ith prednisolone( initiated at @<mg9day% ? 3hortness of breath and arthralgia resolved= chest A)ray findings persisted% ? >ischarged on prednisolone 15mg9day and later commenced on azathioprine :<<mg9day 'ith a reduction in prednisolone to 5mg9day% ? Referred to rheumatology in the 0nited Bingdom% History 5n 0B ? 3ummer 1 , significant shortness of breath on e-ertion arthralgia Cushingoid 5nvestigations 4/C normal 23R 54mm in 1st hour C)reactive protein 7CRP8 :+mg9l Normal biochemical profile Normal complement levels C" and C4 Polyclonal rise in gamma globulins Rheumatoid factor )ve

Antinuclear antibody 7ANA8 1,:5@< Positive, o anti)3m( nRNP( Ro and #a Negative, o anti)ds>NA o antineutrophil cytoplasmic antibodies 7ANCA8 o anticardiolipin antibodies% Radiographs o demineralisation at the *CP &oints and 'rists o no erosive changes% A high resolution C. scan of the chest o small bilateral pleural effusions 'ith basal fibrosis >iagnosis and .reatment ? Results confirmed the diagnosis of 3#2 ? Prednisolone dose increased to 1<mg daily ? Hydroxychloroquine 4<<mg daily added ? ACathioprine :<<mg daily continued ? Calcichew >" forte 1 tablet bd Progress 3een in the 0B on a yearly basis and in bet'een 'as monitored in Africa 3#2 remained under reasonable control >eveloped type 55 diabetes mellitus( presumed to be steroid related 3ummer :<<", pain in lo'er legs from mid)shaft of tibia to toes( ma-imal in his heels 3ome difficulty 'al$ing Dsteoarthrits, ? tenderness and 'armth in hind feet ? both feet sho'ed mild generalised s'elling% ? peripheral pulses normal . scores, ? hip )<%5 ? lumbar spine )1%@ osteopenia% >iagnosis Calcaneal osteonecrosis: Characterised by death of the constituents of bone marro' Peripheral neuropathy: >eath or damage to peripheral nerves resulting in loss of feeling in the legs% Algodystrophy .his is a comple- of symptoms and signs characterised by severe pain( s'elling( autonomic vasomotor dysfunction and impaired mobility in affected &oint areas% A radiographic picture of the affected &oint area sho's inconsistent demineralisation in a patchy or diffuse distribution% 5t may occur follo'ing trauma