Question of the Week # 466

466. A 60-year-old woman presents to the office with hoarseness, shortness of breath, cough, and bilateral ear pain for the past 3 days. She has experienced similar, but less severe symptoms in the past week. Her past medical history is significant for moderate arthritis of the knees ankles, and wrists for the past 20 years Vital signs are:
temperature 37 C (98.6 F)
blood pressure 120/90 mm Hg
pulse 82/min
Respirations 12 breaths/min

On physical examination, the external ears are tender to touch with the exception of the lobule of the ear. There is no hearing loss. There is a saddle-nose deformity. The lungs have minimal bibasilar rhonchi. Abdominal examination reveals a normal-size spleen and liver. The ankle and knee joints are tender but not erythematous. Chest x-ray demonstrates focal tracheal narrowing. Which of the following is the most appropriate management for this patient at this time?

A An arthrocentesis of the knee joint
B Order knee and ankle x-rays
C Prescribe corticosteroids
D Prescribe nonsteroidal anti-inflammatory drugs
E Schedule a bronchoscopy

19 Responses

  1. This sounds like sarcoidosis flare with inflammation or metastatic calcification of the ear due to hypercalcemia, tracheal stenosis, saddle nose, poly arthritis and lung infiltrates. I would give her steroids. But I don’t know if the tracheal stenosis needs some urgent intervention or not!!!

  2. Answer is probably bronchoscopy to make a definitive diagnosis of sarcoidosis prior to starting steroids.

    • The question has a big problem: In a patient of this age, 60, with probable comorbities, long term joint involvement, the medications that this patient probably take. IF the patient does NOT take any meds it should be mentioned and not implied; because it looks like more it was forgotten. As for the answer for the question as it is it looks to me that the next step would be a Broncospy for visualization and biopsy. Letters C and D refers to treatment which should only be done after a Dx is done. Letter A is wrong because there is no mention of joint effusion in the physical exam. Letter C will be too unspecific and not enough to close a Dx.

  3. wegener’s granulomatosis ? answer C

  4. Poly chondritis due to some form of vasculitis. And it probably needs to be treated with steroids or NSAIDs. Answer c or d. And with that I shall stop my second guessing monologues!!!

  5. I do not know how OA combines with saddle nose and tracheal stenosis .In any case the clinical picture is not clear as it is .
    I would start with answer D

  6. I think this patient is having a flare up of her existing Rheumatoid Arthritis (tender ankles and knees on examination) but this episode is more serious (and warrants close monitoring because respiratory flare up which is pre-eminent right now, can be lethal). One thing that is absolutely necessary (most appropriate) at this time is to start steroids (corticosteroids, option C).
    Someone may ask, what if there is a viral or syphilitic or granulomatous component here? How do we exclude these?
    Viral?, no history of recent flu or cold symptoms.
    Syphilis?, how will syphilis travel through the otic nerve and spare the function of hearing. This patient can hear normally.
    Granulomatous disease?, the chest X-ray, vitals, lungs, liver and spleen show no sign of granulomatous infiltrate. Just for laughs, seriously how can an elephant (granulomatous disease) pass through a rice paddy (organ systems) without signs or tracks?
    In this question, there is evidence of (acute) rheumatoid arthritis (tender joints), there is chronic history of rheumatoid arthritis and there is acute involvement of selective respiratory connective tissue (ear cartilage, bronchioles, trachea).
    Finally, might I remind us that Bronchiolar and tracheal inflammation are potentially lethal if left untreated. Therefore, the options that might cause delay (that is, Options A & B) are not acceptable here either. (That is, Options A & B)
    Why not NSAIDs? (Option D) the answer is that their anti-inflammatory effect is not as strong and reliable as steroids, even though their acute analgesia can be phenomenal.
    Option C makes more sense than any other option. This is not the time for tracheal manipulation (Option E, that is bronchoscopy- this procedure can aggravate the tracheal obstruction) It is not time for tracheostomy either! Her vitals her remarkably normal. This is the time to control a pre-eminent respiratory flare with steroids. Remember NSAIDS control pain, anti-inflammatory response to NSAIDS is unreliable and varies considerably from patient to patient. Preventing airway obstruction from inflammatory reaction is our goal right now even though her joint tenderness might benefit from NSAIDS. My answer is Option C. Thank you.

  7. This patient has Relapsing Polychondritis, and should be treated with NSAIDS.
    Relapsing Polychondritis is charactarized by: inflammation of ears, nose, joints and reap tract.

  8. This is a case of Relapsing Polychondritis and the treatment is NSAIDS.

  9. Relapsing polychondritis, also known as atrophic polychondritis,[2] systemic chondromalacia[2]) chronic atrophic polychondritis, Meyenburg-Altherr-Uehlinger syndrome, is a multi-systemic condition characterized by inflammation and deterioration of cartilage. The often painful disease can cause joint deformity and be life-threatening if the respiratory tract, heart valves or blood vessels are affected. The exact mechanism is poorly understood, but it is thought to be related to an immune-mediated attack on particular proteins that are abundant in cartilage.
    Treatment may involve symptomatic treatment with painkillers or anti-inflammatories, and more severe cases may require suppression of the immune system.
    My answer is C

  10. Pt has Wegener. She is stable so no need immediate treatment. Schedule for bronchoscopy to do lung biopsy and confirm the Ds

  11. The correct answer is C .
    It is Wegener with Necrotizing granulomas of the skin, upper resp. tract ( nasopharinx – saddle nose deformity , chronic sinusitis , collapse of trachea ) , lower resp tract ( cavitating nodular lesions ) There are also changes in the kidneys with crescentic glomerulonephritis c -ANCA antibodies 90 % of cases . Treatment is corticosteroids

  12. ans : C
    relapsing polychondritis. treated with systemic steroid.
    whoever said it first hats off, you made me look this up & there is a wonderful article about it on medscape/ emdicine.

    Please dont forget to look up multimedia slides on that site for polychondritis, you will never forget this entity.

  13. Relapsing Polychondritis is diagnosis give steroids

  14. i agree with C, its absurd to do bronchoscopy with an elderly patient with tracheal stenosis, the history is clearly a systemic inflammatory flare up to her chronic and acute history of RA and soft and connective tissue involvement, treat with corticosteroid therapy.

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