Contributed by Wen-Wei Chung, MD, PhD, William Pasculle, ScD
Published on line in March 1999
This 75-year-old white male was admitted to the medical center complaining of chest pain radiating to his left arm, which was relieved by nitroglycerin, and pain in the left wrist and elbow. He had a complex past medical history which included hypothyroidism, chronic obstructive pulmonary disease (COPD), coronary atherosclerosis treated with bypass surgery, multiple transient cerebral ischemic attacks treated with vertebrobasilar angioplasty, and repairs of an abdominal aortic aneurysm and bilateral iliac artery aneurysm repairs. Eight months prior to the present admission he underwent a left orchiectomy for epididymitis and orchitis which had been refractory to antibiotics.
On admission, he was found to have several stenoses in the coronary arteries. On the second hospital day, he received a percutaneous transcoronary angioplasty of the saphenous vein graft to his left anterior descending coronary artery. Following the procedure, his chest pain subsided. He continued, however, to have pain in the wrist and elbow. Masses were present on his left wrist (4x4 cm) and right elbow (3x2 cm) which the patient noted had been present for about six months prior to admission. The joint pain began intermittently but became more persistent over the month prior to admission. The pain was not related to length or amount of activity. He denied any trauma to the joints or previous joint problems. He was treated for gouty arthritis and both joints were injected with corticosteroids without relief of symptoms. He was then started on prednisone (20 mg b.i.d.) and topical lidocaine and prilocaine cream. Sodium urate crystals were found in fluid aspirated from his left wrist and prednisone was continued. When there was no improvement in his symptoms, the prednisone was tapered and X-ray films of the left wrist were taken. Subsequently, the patient underwent arthroscopic biopsy of the joints.
The patient had no history of immunosuppression, cancer, or chemotherapy. He did have an intermittent cough but he denied any asthma, sputum production, and shortness of breath, fever, or weight loss. On physical exam, bibasilar crackles were observed.
X-ray of the right elbow joint taken in at the time of admission (Figure 1): There was loss of articular cartilage of the capitulum, the radial head, and moderately of the trochlea on the olecranon process of the ulna. There were ill-defined intra-articular bodies anterior to the ulna. These findings were consistent with tuberculous (TB) arthritis. X-ray of the chest taken about two weeks after admission (Figure 2) showed an ill-defined area of parenchymal infiltration involving the lower lobe of the right lung, consistent with a pneumonia, and minimal amount of right sided pleural effusion. Compared to the chest X-ray taken two years earlier (Figure 3), there were new diffuse interstitial markings, compatible with miliary tuberculosis (TB). Retrospective examination of an earlier chest X-ray (Figure 4), taken 3 months before the joint lesions were first noted, disclosed diffuse reticulonodular pulmonary lesions.