Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is an 18 year old female of Asian descent who presents with fever of around 101 for one week. She has had several two week episodes of sustained fever in the past 1 year associated with fatigue. She has never sought treatment before. However, this time she developed pain in her knees bilaterally 4 days ago and then in her right wrist yesterday. She has also noticed unintentional weight loss over the last six months. She has also noticed a mild pain in her right flank while inhaling deeply which she assumed was a muscle ache from doing yoga classes. No history of UTI, no dysuria, no polyuria, no increased frequency, no history of STI, not sexually active, no history of hiking in tick infested areas, no nausea/vomiting, no headaches/changes in vision or blurry vision. She does mention living in an old house which had lead paint in it at one point (her mom has repainted the house since the lead was discovered); however, she doesn’t think the water system has been upgraded since the house was built.
PMH: History of two URI’s as a child and contracted EBV at age 15. No surgeries or hospitalization.
Physical Exam: Alert and orientated and in no acute distress. Vital signs are HR 89 bpm, RR 20, BP 126/76, Ht 64’, Wt 132 lbs. Knees are mildly swollen bilaterally, full range of motion and mildly tender to palpation. Respiratory exam shows a faint rub in the right lower quadrant, no other adventitious sounds. Skin exam reveals no abnormalities. Cardiovascular, neurologic and abdominal exam are negative.
Labs:
- Antibody testing = dsANA +, Anti-smith Ab +, ESR/CRP elevated, rheumatoid factor -, anti-ccp –
- Joint tap reveals clear fluid with no crystals, protein and WBC within normal limits
- CXR shows mild right sided pleural effusion, no other opacities/abnormalities
- UA negative for pyuria, leukocyte esterase. UA positive for proteinuria 1+
- G and C swab negative
- Lyme Disease Antibody Titers = negative across the board
- Serum Lead Levels = 2mcg/dl (10 mcg/dl is the upper limit of normal)