1- Definition: Subacute polyarticular arthralgias refer to joint pain that affects multiple joints and develops over a period of a few weeks to several months.
2- Possible Diagnosis: One possible diagnosis based on the patient’s symptoms and history is Lyme disease, a bacterial infection caused by the spirochete Borrelia burgdorferi and transmitted by the bite of infected black-legged ticks. The symptoms of subacute polyarticular arthralgias, swelling of the ankles and right knee, and a recent travel history to a endemic area (the Dominican Republic is not known to be endemic for Lyme disease) all suggest Lyme disease as a potential diagnosis.
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a) Rheumatoid arthritis: Rheumatoid arthritis is a systemic autoimmune disease that affects the joints and can cause subacute polyarticular arthralgias, swelling, and joint effusion. The lack of constitutional symptoms, photosensitivity, and a negative rheumatoid factor test can help differentiate it from RA.
b) Osteoarthritis: Osteoarthritis is a degenerative joint disease that can cause joint pain, swelling, and effusion, especially in older individuals. The lack of morning stiffness and the absence of a systemic inflammatory response can help differentiate it from osteoarthritis.
c) Septic arthritis: Septic arthritis is a bacterial infection of the joint that can cause subacute polyarticular arthralgias, swelling, and joint effusion. The presence of a fever, warmth, and tenderness to palpation in the affected joints can help differentiate it from septic arthritis.
Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases 2006; 43(9): 1089-1134.
Centers for Disease Control and Prevention. Lyme disease. https://www.cdc.gov/lyme/index.html.
Arthritis Foundation. Osteoarthritis. https://www.arthritis.org/diseases/osteoarthritis.
Subacute polyarticular arthralgias • swelling of the ankles and right knee • recent travel to the Dominican Republic • Dx?
A 78-year-old woman with a history of anxiety and hypertension presented to our family medicine residency practice in Massachusetts with subacute polyarticular arthralgias that had been present for 2 months. She complained of pain and swelling of both ankles and the right knee. She noted that her symptoms had started on a recent trip to the Dominican Republic, where she developed generalized joint pain and a fever that lasted 1 to 2 weeks and subsequently resolved with the lingering polyarthralgia. She denied any rash,
constitutional symptoms, photosensitivity, headaches, photophobia, or history of tick bite. Physical examination revealed normal vital signs, notable warmth and swelling of the bilateral ankles that was worse on the right side, and swelling of the right knee with effusion—but no tenderness—to palpation.
2- Possible Diagnosis with rationale explanation.
3-At least 3 differentials must be mentioned with rationales explanation.
at least 3 references with no less then 5 years