A 27-year-old African American woman comes to the office due to 6 weeks of pain and swelling of her hands and wrists. The pain worsens in the morning and is associated with stiffness for 10-15 minutes. She also has had easy fatigability and muscle aches. The patient has no significant medical history and does not take any medications. She has been sexually active with a new partner. Temperature is 37.9 C (100.2 F), blood pressure is 140/90 mm Hg, and pulse is 76/min. Physical examination shows slightly swollen, tender metacarpophalangeal and proximal interphalangeal joints. There is a nontender ulcer on the buccal mucosa. Mild cervical and axillary lymphadenopathy are present. Cardiopulmonary auscultation is normal. The abdomen is soft and nontender. Laboratory results are as follows: X-ray of the hands and wrists reveals no bony erosions. Urinalysis shows 2+ protein and 20-30 red blood cells/hpf. Which of the following is the most likely diagnosis?

Question

A 27-year-old African American woman comes to the office due to 6 weeks of pain and swelling of her hands and wrists.  The pain worsens in the morning and is associated with stiffness for 10-15 minutes.  She also has had easy fatigability and muscle aches.  The patient has no significant medical history and does not take any medications.  She has been sexually active with a new partner.  Temperature is 37.9 C (100.2 F), blood pressure is 140/90 mm Hg, and pulse is 76/min.  Physical examination shows slightly swollen, tender metacarpophalangeal and proximal interphalangeal joints.  There is a nontender ulcer on the buccal mucosa.  Mild cervical and axillary lymphadenopathy are present.  Cardiopulmonary auscultation is normal.  The abdomen is soft and nontender.  Laboratory results are as follows:  X-ray of the hands and wrists reveals no bony erosions.  Urinalysis shows 2+ protein and 20-30 red blood cells/hpf.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d526_a812_bc81_d7aed8651ed5_MD0003_00 This patient's fatigue, polyarticular arthritis, painless oral ulcer, thrombocytopenia, and likely glomerulonephritis (hematuria, proteinuria) raise strong suspicion for systemic lupus erythematosus (SLE), a multisystem, inflammatory disorder most common in young, African American women. Arthritis and arthralgias affect 95% of patients with SLE and tend to be migratory, symmetric, polyarticular, and accompanied by brief morning stiffness (much shorter in duration than rheumatoid arthritis [RA]). The knees, carpal joints, and joints of the fingers are most commonly affected. Joint pain often exceeds the objective findings on examination, and x-rays usually reveal no evidence of joint destruction or erosion (unlike other inflammatory arthritides such as RA). Other common manifestations of SLE include malar rash, serositis (eg, pericarditis), neuropsychiatric complications, and thromboembolic events. Lymphadenopathy often occurs as a primary manifestation (~50% of cases). rash (Choice A) Behçet disease typically presents with multiple oral and genital ulcers that are recurrent and painful. Uveitis is common. This patient has a nonpainful oral ulcer and hematologic and renal abnormalities, which are not typically seen with Behçet disease. (Choice B) Disseminated gonococcal infection can cause a purulent arthritis or the triad of tenosynovitis, dermatitis (eg, 2-10 painless pustules on the distal extremities), and polyarthralgia. Thrombocytopenia, oral ulcers, and proteinuria would be atypical. (Choice C) Felty syndrome is a potentially serious complication of RA characterized by neutropenia and splenomegaly. Recurrent bacterial infection is common (due to neutropenia) and may lead to lymphadenopathy. However, most cases occur in patients with long-standing erosive RA; this patient's short-duration morning stiffness, normal joint findings on x-ray, and lack of splenomegaly make Felty syndrome unlikely. (Choice D) Hodgkin disease can cause systemic symptoms and lymphadenopathy; it is also associated with minimal change disease and nephrotic syndrome. However, oral ulcers, synovitis, and glomerulonephritis (red blood cells on urinalysis) would be uncommon. (Choice E) Most adults with parvovirus infection are asymptomatic or have flulike symptoms. A minority may develop a self-limited, symmetric, nonerosive arthritis, but the prolonged duration of symptoms (>3-4 weeks) and renal abnormalities (hematuria, proteinuria) make SLE more likely in this patient. (Choice F) Sarcoidosis typically presents with pulmonary and skin findings and can cause interstitial nephritis. However, glomerulonephritis and oral ulcers are unusual. Educational objective: Systemic lupus erythematosus is a multisystem, inflammatory disease that often presents with arthritis and arthralgias. Joint involvement tends to be symmetric, migratory, and nonerosive with brief morning stiffness. The knees, carpal joints, and joints of the fingers are most commonly affected.

A 27-Year-Old African American Woman Comes to the Office Due