36º Congresso Brasileiro de Reumatologia

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Title

DIFFERENTIAL DIAGNOSES IN CLINICAL RESEARCH: THE CONSTANT CHALLENGE OF INFECTIOUS DISEASES IN RHEUMATOLOGY.

Background

Leprosy is an infectious disease that, although easily treatable, remains endemic in our country. Even though its clinical presentation is varied, its main features are the involvement of peripheral nerves and skin. Rheumatological manifestations are also common.

Case report

A.J.S.S., female, Caucasian, 62 years old, complaining of pain in the extremities of hands and feet, associated with edema and loss of distal force, with onset of the condition 2 years ago. She referred to constant pain that worsened in the cold and did not have factors of improvement, besides that, she presented difficulty in flexion of the fingers. At the physical examination, the patient presented bilateral madarosis, systolic cardiac murmur (3 + / 6 +), thickening of the skin, erythema and intense pain at the touch of the extremities of the hands and feet, but without pain to the digitopression of the metacarpophalangeal and metatarsophalangeal joints of the wrists and ankles, and without the presence of arthritis. For diagnostic elucidation, laboratory tests with thyroid function, viral serologies, FAN and VDRL, as well as chest X-ray and transthoracic echocardiography were requested and Prednisone 15 mg/day was prescribed. In the return to the doctor´s office, she presented partial improvement of the pain in the extremities after steroid therapy for 3 weeks, which she suspended on her own due to significant changes in glycemia. The laboratory test showed elevated ESR (83) and CRP (0.2), negative viral serologies while the transthoracic echocardiography revealed a posterior wall akinesia, grade I diastolic dysfunction, thickened aortic and mitral valve. The patient was referred to endocrinology and cardiology, with prescription of Amitriptyline for neuropathic pain. After two weeks, however, she was admitted to the emergency room with edema in the joints of the hands and feet, worsening of pain in the extremities and erythematous infiltrative, nodular and pruritic lesions diffused by the body (Image 3), started 7 days ago, compatible with leprosy. Due to the diagnostic suspicion, the patient reported that her son has the disease and doesn’t accept the treatment. Corticosteroid therapy was established during hospital stay, with strict glycemic control, and then she was referred to the referral treatment program.

Conclusion

The case reported portrays a clinical deadlock, evidencing the importance of maintaining the range of possibilities open during the entire diagnostic study. It’s essential to consider the epidemiological context in which the patient is inserted, this should serve as a beacon to the clinical investigation.

Arquivos

Área

Endemic Diseases

Autores

Fernanda Marvila Fagundes Lamarca, Flávio Ribeiro Pereira, Jannine Farias Bellini Leite, Isabella Matias Ribeiro, Nádia Christina Maia Moreira, Ingrid Carvalho Andrade, Natália Miranda Gava, Paula Amanda Starling Alves