A 25-year-old woman comes to the office to be evaluated for arthritis. The patient has had 3 months of pain and swelling of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hands and the metatarsophalangeal (MTP) joints. She feels stiffness in her hand joints upon awakening in the morning that lasts approximately 2 hours. The patient has also had fatigue and decreased appetite. She has a history of severe acne but has had no cardiac or pulmonary problems. The patient's only medication is minocycline, which she began taking 6 months ago. She does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.2 C (99 F), blood pressure is 122/70 mm Hg, and pulse is 89/min. Skin examination is notable for an erythematous rash on sun-exposed areas. Cardiopulmonary auscultation is normal. There is swelling and tenderness of the MCP, PIP, and MTP joints. Trace effusions are present in the elbows. The remainder of the examination, including testing for muscle strength, is within normal limits.
Laboratory results are as follows:
Chest x-ray is normal.
Which of the following is the most likely diagnosis in this patient?

Question

A 25-year-old woman comes to the office to be evaluated for arthritis.  The patient has had 3 months of pain and swelling of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hands and the metatarsophalangeal (MTP) joints.  She feels stiffness in her hand joints upon awakening in the morning that lasts approximately 2 hours.  The patient has also had fatigue and decreased appetite.  She has a history of severe acne but has had no cardiac or pulmonary problems.  The patient's only medication is minocycline, which she began taking 6 months ago.  She does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.2 C (99 F), blood pressure is 122/70 mm Hg, and pulse is 89/min.  Skin examination is notable for an erythematous rash on sun-exposed areas.  Cardiopulmonary auscultation is normal.  There is swelling and tenderness of the MCP, PIP, and MTP joints.  Trace effusions are present in the elbows.  The remainder of the examination, including testing for muscle strength, is within normal limits.
Laboratory results are as follows:
 Chest x-ray is normal.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_9926_89e3_853d_13ec4ef50cf2_MD0002_00 Drug-induced lupus erythematosus, which resembles idiopathic systemic lupus erythematosus (SLE), is an autoimmune syndrome that can be triggered by a number of medications. Common causes include procainamide, hydralazine, isoniazid, and tumor necrosis factor-alpha inhibitors. Although the relative risk is significantly lower with the antibiotic minocycline, minocycline-induced lupus may be more commonly encountered in clinical practice due to the widespread use of this drug in the treatment of acne. Common symptoms in drug-induced lupus include fever, malaise, myalgias, and arthralgias. Pleuritis is common in procainamide-induced lupus but uncommon with minocycline. Most patients do not develop the typical SLE malar rash, although drug-induced lupus may cause scaly, papulosquamous plaques (typically in a photodistributed pattern but often sparing the face) reminiscent of subacute cutaneous lupus. End-organ (eg, kidney, central nervous system) manifestations are significantly less common in drug-induced lupus than in SLE. Most patients with drug-induced lupus (95%-100%) have a positive antinuclear antibody assay, particularly histone autoantibodies, but anti-double-stranded DNA and anti-Smith antibodies are rare. Also, drug-induced lupus is less likely to cause cytopenias and complement depletion. Discontinuation of the inciting drug usually leads to gradual resolution of symptoms. Nonsteroidal anti-inflammatory drugs and topical and systemic glucocorticoids can be used to alleviate symptoms if needed. (Choice A) Adult-onset Still disease can present with arthritis and rash, but the rash is evanescent and salmon-colored, and patients typically also have high fever and leukocytosis. Marked ferritin elevations are classic. (Choice B) Dermatomyositis may occasionally present with skin involvement but without muscle weakness or elevated creatine kinase levels ("dermatomyositis sine myositis"). However, characteristic findings in these cases include a heliotrope rash at the eyes and Gottron papules at the fingers. heliotrope rash Gottron papules (Choice C) Typical findings in diffuse systemic sclerosis include skin thickening in the trunk, face, and extremities (sclerodactyly) and Raynaud phenomenon, rather than the hand arthritis seen in this patient. (Choice E) Mild elevations in liver transaminases may be seen in minocycline-induced lupus but would be unlikely in seronegative rheumatoid arthritis, which would also not cause this patient's skin findings. Educational objective: Drug-induced lupus erythematosus resembles systemic lupus erythematosus, but is less likely to cause central nervous system or renal disease, hematologic abnormalities, or low complement levels. Common triggers include hydralazine, procainamide, anti-tumor necrosis factor agents, and minocycline. Discontinuation of the inciting drug usually leads to resolution. __________ References: Drug-induced lupus erythematosus: incidence, management and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/21513360)

A 25-Year-Old Woman Comes to the Office to Be Evaluated