CASE 57: COUGH AND JOINT PAINS
History
A 29-year-old man presents with a cough and some mild aches in the hands, wrists and
ankles. The symptoms have been present for 2 months and have increased slightly over
that time. Six weeks before he had some soreness of his eyes, which resolved in 1 week.
The cough has been non-productive. He had noticed some skin lesions on the edge of the
hairline and around his nostrils. Previously he had been well apart from an appendicec-
tomy at the age of 17 years.
He was born in Trinidad and came to the UK at the age of 4 years. His two brothers and
parents are well. He does not smoke, is teetotal and takes no recreational drugs. He works
as a messenger and took regular exercise until the last few weeks.
Examination
There is no deformity of the joints and no evidence of any acute inflammation. In the
respiratory and cardiovascular system there are no abnormal findings. In the skin there
are some slightly raised areas on the edge of the hairline posteriorly and at the ala nasae.
They are a little lighter than the rest of the skin.
NormalHaemoglobin 13.5 g/dL 13.0–17.0 g/dL
Mean corpuscular volume (MCV) 88 fL 80–99 fL
White cell count 8.5% 109 /L 3.5–11.0% 109 /L
Platelets 264 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 34 mm !10 mm/h
Sodium 140 mmol/L 135–145 mmol/L
Potassium 4.0 mmol/L 3.5–5.0 mmol/L
Urea 3.6 mmol/L 2.5–6.7 mmol/L
Creatinine 74 &mol/L 70–120&mol/L
Bilirubin 14 mmol/L 3–17 mmol/L
Alkaline phosphatase 84 IU/L 30–300 IU/L
Alanine aminotransferase 44 IU/L 5–35 IU/L
Calcium 2.69 mmol/L 2.12–2.65 mmol/L
Phosphate 1.20 mmol/L 0.8–1.45 mmol/LThe chest X-ray is shown in Fig. 57.1.