En mann med feber og leddsmerter

A Norwegian man in his sixties was admitted to the Department of Medicine owing to severe pain in the right ankle. The pain was accompanied by intermittent fever above 39 °C. Apart from hospitalisation for malaria in 2011, he had otherwise been mostly in good health. The patient took Albyl-E 75 mg 1 1 as primary prophylaxis against heart disease. He had returned to Norway five days earlier from a stay abroad. During the journey and for two weeks prior to admission, he had noticed transient nasal congestion and a sore throat. Upon admission he had increasing pain in the right ankle. He had sprained the ankle a month earlier, but there was no major trauma in his case history. He also reported general pain in the shoulders, back and left hip. Upon arrival at the hospital, the patient had a high fever with temperature 39 °C, normal blood pressure (119/65), and a steady pulse of 86. Auscultation of the heart and lungs was normal. He had diffuse rubor on both the medial and the lateral side of the right ankle, as well as warmth and a petechial rash over the ankle joint (Fig. 1). Blood tests on admission revealed CRP 248 (< 5 mg/l), leukocytes 21.5 (3.5 – 11.0 109/l) with neutrophil granulocytes 19.4 (1.7 – 8.2 109/l), thrombocytes 186 (145 – 348 109/l), INR 1.3 (< 1.1), sedimentation rate 15 (1 – 20), creatinine 92 (60 – 105), bilirubin 26 (< 19), LD 244 (105 – 205) and CK 79 (40 – 280). The orthopaedic surgeon was consulted in the emergency ward. By this stage the blood test results were also available. Diagnostic puncture of the ankle joint was indicated, but not X-ray examination of the ankle. A total of 2 – 3 ml of opaque synovial fluid was drained from the right ankle around midnight on the day of admission, but drainage of all of the synovial fluid was not possible due to pain. The synovial fluid was sent for cultivation and microscopy, but not for cell counting.