Dados do Trabalho

Title

INFECTIOUS DISEASES IN RHEUMATOLOGY: THE EXTENSIVE CHALLENGE OF DIFFERENTIAL DIAGNOSES.

Background

Syphilis is a very prevalent condition in our country, which, although easily treatable, has a rising incidence. Even if its endowed with classical and widely recognized manifestations, we must admit its multifaceted phenotypic potential, which can be similarly designated to an infinity of other diseases.

Case report

E.V.N.G., 28 years old, Caucasian, previously healthy, complaining for 1 month of peripheral and axial polyarthralgia, without edema or joint stiffness, improving with the use of anti-inflammatories. Refers skin rash at the beginning of the clinical condition, denying fever and loss of weight. In the physical exam, joint mobilization pain without cutaneous lesions or lymphadenopathy was visualized. Considering the epidemic status of Chikungunya infection in the region, laboratory tests - including serologies - were requested as well as anti-inflammatory and injectable depot corticosteroid were prescribed. After two weeks, he showed partial improvement of the articular manifestations, however evolved with scotomas and bilateral visual turbidity, predominantly to the right. The laboratory showed high VHS (10) and CRP (18.4), elevated transaminases and FAN 1/320 dense fine dotted nuclear pattern. The patient was referred to an ophthalmologist, being requested new serologies and autoimmunity markers. Ophthalmologic examination revealed bilateral hyperemia of the optic disc associated to discreet edema, more significant to the right. Prednisone 40 mg / day was started and Magnetic Resonance of skull and campimetry were requested, both without changes, besides fluorescein angiography, which confirmed optic neuritis (Image 1). The patient returns to the rheumatology clinic presenting serology for Chikungunya IgM 0.9 indeterminate and IgG negative including VDRL 1/32; other serologies and autoimmunity markers were negative. He was hospitalized, then a cerebrospinal fluid (CSF) sample was collected and antibiotic therapy with crystalline penicillin G was started. The CSF study showed 17 leukocytes, FTA-ABS IgG and ELISA IgG positive for syphilis. After weaning from the corticosteroid, in two months of evolution, there was complete remission of the condition, without joint or visual sequels.

Conclusion

The case reported portrays a clinical dilemma, evidencing the importance of keeping the range of options open throughout the diagnostic study. It is essential to consider the epidemiological context the patient is in it, however, this should serve as a beacon to the investigation and not control it. Syphilis is famous for being a mimic of diseases and, because of that, often compels us to reserve it in our list of differential diagnoses.

Arquivos