By: Anisha B. Dua, MD, Joshua Waytz, MD, both of Northwestern Medicine Rheumatology
A 58-year-old man presented to a Northwestern Medicine emergency department (ED) after a week of joint pain and confusion.
History of present illness
The patient initially developed left shoulder pain one week before presenting at the ED. The pain spread to his right shoulder, at which point he developed significant difficulty moving as a result of impaired shoulder abduction and frank weakness in the entire right arm. He was not able to reach above his head or lift items.
Over the following week, pain spread to his bilateral wrists, which became red and swollen. His husband noticed that the patient was more fatigued and confused than usual. Of note, the patient had memory limitations at baseline due to a prior aneurysm rupture. Due to fatigue and weakness, the patient fell, landing on his right hand, prompting him to get an evaluation in the ED.
The patient did not have any other joint pain, rashes, nausea, abdominal pain, diarrhea, dysuria, penile discharge or lesions, upper respiratory symptoms or visual symptoms. He and his husband have a pet dog, but the patient had not been bitten recently. The patient was surprised to learn that when he presented to the hospital, he was febrile.
Past medical history
The patient had well-controlled HIV on highly active antiretroviral therapy (elvitegravir/cobicistat/emtricitabine/tenofovir) with a CD4 count of 414 cells/mm3. He also had Type 1 diabetes that was well managed with an insulin pump.
He had a remote history of a subarachnoid hemorrhage due to a posterior inferior cerebellar artery aneurysm. The aneurysm was coiled, and the patient had a ventriculoperitoneal shunt placed. He has had no additional aneurysms. Other than previously mentioned short-term memory issues, he had no residual effects from this episode.
The patient had hypertension and hyperlipidemia (managed with lisinopril and pravastatin), and acid reflux (managed with omeprazole).
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