JCR: Journal of Clinical Rheumatology:
What's the Diagnosis?
Shumacher, H. Ralph
This unusual joint fluid was aspirated from a swollen, painful knee joint. What would your concerns be, and what do you think the patient had? Note the very dark joint fluid (Fig.1). Please look at this in color on our website http://www.jclinrheum.com. E-mail your responses and ideas to the editor at email@example.com with “puzzling case” in the subject line.
The answer will be in the next issue of the JCR and on the website http://www.jclinrheum.com.
Answer to the February 2002 case by Antonio Reginato
Physical findings in the patient shown at right included clubbing of the toes, which might have looked even more definite with lateral views. There was also livedo reticularis. The radiographic findings were key with periarticular demineralization and periosteal reaction along the femurs in both knees.
Clubbing alone or hypertrophic osteoarthropathy localized to the lower extremities occurs only in patients with ductus arteriosus who have developed right to left shunting of blood flow secondary to pulmonary hypertension, infected aortic grafts, or intra-abdominal arterial intestinal fistula. Thus in this patient with a previous graft and fever, the final diagnosis was an infected aortic bypass. There was an aortic small intestinal fistula, confirmed by angiogram and surgical exploration.
For further reading:
1. Serin SB, Askari A, Rhodes RS. Hypertrophic osteoarthropathy of the lower extremities as manifestations of arterial graft sepsis. Arthritis Rheum 1980; 23:768.
2. Stein HB, Little HA. Localized hypertrophic osteoarthropathy in the presence of abdominal aortic prosthesis. Can Med Assoc 1978; 188:947.
3. Gibson T, Joye J, Schumacher HR, Agarwal B. Localized hypertrophic osteoarthropathy associated with an abdominal aortic prosthesis and infection. Ann Int Med 1974; 81:556–7.
© 2002 Lippincott Williams & Wilkins, Inc.