Just in case readers of this blog have the impression that I spend most of my time in Swaziland gallivanting around having a long holiday, I thought that I should slip in a few examples of clinical problems I have encountered at the clinic this week.
This is the left hand of a woman in her mid-thirties who is HIV negative*. She says that the last joint of her ring finger has been swollen for three weeks. The index finger was also affected, but that just lasted a few days. It is warm, minimally tender, with a slightly limited range of movement.
OK, doctor, what is going through your mind at this stage?
Initial presentation of rheumatoid arthritis? Unlikely. Doesn’t usually affect terminal interphalangeal joints, more likely to show in proximal joints. No family history . When it just affects one joint, it usually presents in a larger joint, such as a knee, first. Not symmetrical.
Trauma? No history. Relatively pain-free and capable of movement.
Low grade septic arthritis? Commoner in people living with HIV. The symptoms should have been getting worse. No infection of the anterior fat pad of the finger.
TB dactylitis? It occurs, not very common as a presentation of TB, but we see lots of TB, so I didn’t discount it. Or another granulomatous condition, such as sarcoid.
Gout? Not really painful enough. No previous attacks, no podagra.
Skin rashes? Psoriasis? No skin lesions, no nail pitting. Not a “sausage digit”.
Sickle cell? Unlikely in Swaziland.
Underlying bone problem? Growth too rapid for an enchondroma.
Tendon problem? Joint too mobile for this.
Syphilis? Perhaps only a GU physician would think of this!
I asked her about sexually transmitted infections and she denied having any. I was just about to prescribe some anti-inflammatory medication when she started ferreting about in her handbag. She produced a blue “contact slip”, which was the missing piece of the diagnostic jigsaw. Her husband had given her the contact slip when he attended our clinic a few weeks ago suffering from a urethral discharge.
She has sexually acquired reactive arthropathy (SARA). Gonococcal arthritis is also possible but I would have expected her symptoms to have been more florid. I prescribed the same treatment as her husband, along with the anti-inflammatory drug.
The next patient was a woman in her early twenties (HIV positive) with a sore at the corner of her mouth. Diagnosing this condition was easy – angular stomatitis or cheilitis. I most often see this in the UK in older people who wear poorly-fitting dentures (my grandfather used to buy his dentures from a market stall after trying them in). With the thinning of the gums and sagging muscles round the mouth, the lips don’t come together neatly. The overhang of skin at the edge of the vermillion of the lips allows moisture to remain in contact with the skin, predisposing to yeast and bacterial infections. It also occurs in people who are generally unwell, with poor nutritional status, vitamin B or iron deficiency. The continuous presence of saliva can cause an irritant contact dermatitis.
She felt as though she was about to come down with influenza and she also complained of painful lumps under her jaw. Looking carefully, one can see blisters or vesicles. I felt some tender lymph nodes under the mandible. This is a herpetic infection, cold sores, a uncommon presentation of angular stomatitis.
Staying with the oral theme, here is a photograph of some pale lumps on the inside of a patient’s gums. The most likely cause is dental abscesses, but the teeth looked in reasonable condition with no glaring caries. I did a blood test to rule out syphilis. Doctors in UK don’t learn much about teeth in medical school. We are prohibited from treating dental conditions because it would be trespassing on dentists’ territory. I duly referred her to a dentist and gave her some antibiotics and pain killers.
This man is a builder who had been grinding stone blocks. He felt something go into his eye four days before coming to the clinic. I don’t have fluorescein drops or papers, but it was obvious that he has a corneal ulcer. Using local anaesthetic, I numbed the eyeball, scraped out the grain of grit with a 21 needle and irrigated it well. Pain relief, topical antibiotics and review in a couple of days, sooner if he develops problems. Sorted.
* HIV status is so important when assessing a patient that it has become a “vital sign”, along with pulse, temperature, blood pressure, respiratory rate, etc.
Fantastic work Ian. So worthwhile & sincere thanks for sharing your clinical experiences – will help with my (post retirement) education.
Always been a fan of your work, too, Jane.