PGY3 Cesar Gonzalez presented a case of a 80 y/o male with history of seronegative inflammatory RA and immune-mediated interstitial nephritis presents with 2 weeks of acutely worsened bilateral wrist, elbow and knee pains. He reports that he has had painful knees and wrists for the last 2 years, but as of the last 2 weeks, wrist pain has progressively worsened. He describes the pain as dull, 8/10, worse on palpation or movement. Of note, he was admitted recently to OSH for painful joints. He received solumedrol and rituximab and was discharged on a prednisone taper. He reports fevers/chills in the morning, when his pain is at its worst. Home medications include mycophenolate mofetil 1500mg BID and prednisone 10mg qday. The patient was born in Taiwan and moved to the US about 18 years ago. He is retired (used to be a clerk) and denies any pets/fish tanks at home and no drugs/ethanol/tobacco use.
Vital signs: T 36.6C, HR 88, BP 113/55, SpO2 96%
Physical Exam significant for dental caries, L forearm with erythematous thin plaque with oozing erosion in center with mucopurulent drainage, L dorsal hand with erythematous thin plaque and TTP bilateral wrists, elbow and knee. +2-3cm tender mass proximal to L wrist and L wrist effusion > R wrist and L knee effusion > R knee.
CBC: WBC 15 > Hb 10.4/Hct 33.7 <Plt 267
Diff: 89.6% PMN, 0.9% lymph, 2.6% monocytes, 0% eosinophils, 0% basophils
Na 128/K 4.5/Cl 94/HCO3 18/BUN 45/Cr 1.55 <Glucose 214 (baseline Cr 1)
ALP 67>T.protein 5.7/Albumin 2.7/AST 16/ALT 16/Tbili 0.4
Coags:PT 13.7, INR 1, PTT 28.8
Wrist XR showed bilateral positive ulnar variance and subchondral cystic changes of the ulnar aspect of the proximal lunate bilaterally.
Infectious workup significant for elevated ESR and CRP. A Left knee aspiration was done of which culture showed +AFB. Sputum smear and culture for AFB also came back positive.
Rheum workup was largely negative.
L forearm skin biopsy: granulomatous and suppurative dermatitis with AFB
CT Chest showed innumerable bilateral pulmonary nodules within all visualized lobes.
Treatment: Patient was initially started on Vanc and Zosyn for concern of septic joint. Rheum consulted and recommended solumedrol and continuing cellcept. Once Derm biopsy and joint fluid grew AFB, he was started on RIPE therapy with decrease in solumedrol.
Take home points:
- Miliary TB is disseminated TB + radiologic findings
- Consider TB in patients with vague B symptoms (fevers, chills, night sweats, weight loss, etc) from endemic areas
- Treatment: Intensive phase (RIPE x2 months) and Continuation phase (INH + Rifampin x4-7 months)