A Rheumatic Disease? Keep an Open Mind
A Rheumatic Disease? Keep an Open Mind
A 65-year-old man presented to me last week complaining of aches, pains, soreness, and stiffness of his shoulders and pelvic areas, along with fatigue, weakness, and weight loss. His medical history was significant for the antiphospholipid syndrome. Ten years ago, the patient became depressed and forgetful and was placed on an antidepressant by his psychiatrist. This previously highly intelligent businessman became increasingly cognitively impaired and was eventually seen by a neurologist, who found no focal neurologic deficits, but an MRI showed diffuse white matter ischemic changes consistent with multiple strokes. The patient was found to have immunoglobulin (Ig)G and IgM antiphospholipid antibody titers >100 and a lupus-type circulating anticoagulant. An echocardiogram showed a large vegetation on the mitral valve. Blood cultures and routine blood tests and serologic tests were negative. He had no clinical or laboratory manifestations of systemic lupus erythematosus (SLE), including no arthritis, skin rash, Raynaud phenomenon, fatigue, fever, antinuclear antibodies (ANA), antibodies to double-stranded DNA, elevated sedimentation rate, elevated C-reactive protein level, cytopenia, or renal abnormalities.
Recent history. The patient was treated with heparin and warfarin, which resulted in disappearance of the mitral valve lesion and moderate improvement in his cognition, but he was still not able to work. One month ago, the patient became stiff and was unable to navigate around his apartment or outside. He developed increasing soreness, stiffness, and pain in the shoulders, pelvic area, back, and thighs, particularly in the morning, with no redness, warmth, swelling, or pain in the hands, wrists, ankles, or feet. He denied a history of headache, visual changes, jaw pain with eating, double vision, tongue pain or scalp tenderness, fever, chills, or night sweats but had significant fatigue. He had lost 5 pounds in the last month with no change in diet.
Physical examination. The patient's vital signs were within normal limits. He exhibited moderate cognitive impairment and no skin rash. Findings of a general examination were normal. No scalp tenderness, prominent or tender temporal arteries, or visual abnormalities were found, and an ophthalmologic examination was normal. He had tenderness and restricted range of motion about the shoulders, hip, and thigh region and strength of 4/5 in the arms and legs proximally, which was probably related to pain rather than weakness. His distal strength was normal. There was no synovitis in the other peripheral joints, and all joints showed full and painless range of motion.
Clinical Presentation
A 65-year-old man presented to me last week complaining of aches, pains, soreness, and stiffness of his shoulders and pelvic areas, along with fatigue, weakness, and weight loss. His medical history was significant for the antiphospholipid syndrome. Ten years ago, the patient became depressed and forgetful and was placed on an antidepressant by his psychiatrist. This previously highly intelligent businessman became increasingly cognitively impaired and was eventually seen by a neurologist, who found no focal neurologic deficits, but an MRI showed diffuse white matter ischemic changes consistent with multiple strokes. The patient was found to have immunoglobulin (Ig)G and IgM antiphospholipid antibody titers >100 and a lupus-type circulating anticoagulant. An echocardiogram showed a large vegetation on the mitral valve. Blood cultures and routine blood tests and serologic tests were negative. He had no clinical or laboratory manifestations of systemic lupus erythematosus (SLE), including no arthritis, skin rash, Raynaud phenomenon, fatigue, fever, antinuclear antibodies (ANA), antibodies to double-stranded DNA, elevated sedimentation rate, elevated C-reactive protein level, cytopenia, or renal abnormalities.
Recent history. The patient was treated with heparin and warfarin, which resulted in disappearance of the mitral valve lesion and moderate improvement in his cognition, but he was still not able to work. One month ago, the patient became stiff and was unable to navigate around his apartment or outside. He developed increasing soreness, stiffness, and pain in the shoulders, pelvic area, back, and thighs, particularly in the morning, with no redness, warmth, swelling, or pain in the hands, wrists, ankles, or feet. He denied a history of headache, visual changes, jaw pain with eating, double vision, tongue pain or scalp tenderness, fever, chills, or night sweats but had significant fatigue. He had lost 5 pounds in the last month with no change in diet.
Physical examination. The patient's vital signs were within normal limits. He exhibited moderate cognitive impairment and no skin rash. Findings of a general examination were normal. No scalp tenderness, prominent or tender temporal arteries, or visual abnormalities were found, and an ophthalmologic examination was normal. He had tenderness and restricted range of motion about the shoulders, hip, and thigh region and strength of 4/5 in the arms and legs proximally, which was probably related to pain rather than weakness. His distal strength was normal. There was no synovitis in the other peripheral joints, and all joints showed full and painless range of motion.
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