Knee And Ankle Swelling—Daily Walker

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HISTORY: A 68-year-old woman who walks daily presented to sports medicine clinic with left ankle and knee pain and swelling. Her pain started three weeks prior to presentation in her left ankle followed by redness and swelling. Several days later her left knee became painful, swollen, and red. She was unable to participate in her daily walks, and the pain started to wake her from sleep. The pain was described as achy and stiff. She had tried treatment with Naproxen and Tylenol without relief. No known injuries or tick bites. She denied fevers, previous joint pain, rash, or rheumatologic history. Several days before the onset of her joint pain she was seen in the emergency department for diarrhea. PHYSICAL EXAM: She was afebrile with a nontoxic appearance with significant joint effusions of the left knee and ankle with erythema. Diffuse tenderness to palpation over both joints. Range of motion of the ankle and knee were limited by effusions and pain. Strength was 5/5 with knee flexion/ extension, ankle dorsiflexion/ plantar flexion. Ligamentous and meniscal exams were limited by pain. Her gait was antalgic. DIFFERENTIAL: 1. Lyme or tick related illness 2. Reactive arthritis 3. Rheumatic arthritis 4. Gout/ pseudogout 5. Septic arthritis TEST AND RESULTS: X-ray of her left ankle obtained prior to her appointment showed an effusion. Blood work was notable for: negative tick-borne Ab panel. Elevated ESR (81), and CRP (9.9). Uric acid within normal limits. CBC with mildly elevated WBCs. CMP unremarkable. HLA B27 Positive. CCP antibodies and RF negative. Left knee joint aspirate was obtained via ultrasound guidance, and notable for: negative tick-borne PCR and crystals. Uric acid within normal limits. Smear: 3+ polymorphonuclear white blood cells. Culture with no growth. Stool cultures returned positive for Salmonella Enteritidis FINAL/ WORKING DIAGNOSIS: Salmonella Enteritidis reactive arthritis. TREATMENT AND OUTCOMES: Patient was seen by rheumatology where 40 mg prednisone daily was started for treatment of reactive arthritis with improvement in her pain within days. She had a prolonged treatment course due to viral infections that required intermittent discontinuation of her prednisone treatment. At an appointment after prednisone was completed, she had resolution of the effusions, and was able to walk pain-free.